Surgical Treatment For Tophaceous Gout In Extremities

ObjectiveThe prevalence of gout is increasing to date.But because of the deficits in both patients' and physicians' knowledge,gout is usually poorly managed.When gouty tophi develop and cause deformities and joint destruction,surgical interventions must be considered.However,surgical guidelines for tophaceous gout are absent.In this review,we will discuss the necessity of surgical interventions and review some clinical experiences during the treatment of patients with tophus in extremities to summarize the treatments of tophaceous gout.MethodsFrom February 2012 to December 2015,a total of 95 patients(92 males and 3 females)with chronic tophaceous gout in the extremities underwent surgical treatment in our center.Patients in this group aged from 15-82 years old,with an average age of 51 years old.All the 95 patients accepted operative treatments between attacks,the average SUA was 565?mol/L and the average size of tophus was 4 cmx3 cm.The patient's ability to bear the operation was evaluated,the history in detail and the serum uric acid were recorded before surgery.We classified the tophaceous gout into I-IVstages according to the size of the tophi and the involvement of the surrounding tissues.Estimate the operation time and blood loss according to the usual operation experience.If the affected joints were more than 15,a secondary operation would be considered.If the joint was involved,arthroplasty and arthrodesis would be considered.Arthroplasty was always the first choice especially for the metacarpophalangeal joint and the proximal interphalangeal joint.But as for the metatarsophalangeal joint,arthrodesis was performed when the articular surface were loss severely.There were 7 cases of skin defect,area ranged from 1.0cm×1.0cm to 4.0cm×3.0cm.Of those,3 cases with tendons exposed underwent skin flap prothesis.The other 4 cases accepted dressing changes on the wounds.ResultsA total of 6 patients accepted amputations due to serious infection,1 of middle finger,2 of toes,2 of right shank and 1 of left shank.The serum uric acid(SUA)was rechecked within 3 to 7 days after operation.All the patients were asked to follow up at the 3 weeks,6 weeks and 6 months after operation.Patients with ulcerated tophaceous gout stayed in hospital for 13.1 days longer than those without ulceration(7.8 days).The average SUA levelwas 484?mol/L,which was decreased significantly after operation.After the initial surgery,72 patients were followed up from 1.2years to 5years.All patients were satisfied with the appearance.The function had been improved greatly.Range of motion on upper limbs was increased significantly and the joints on lower limbs load without pain and stabilization.The frequency of acute gouty arthritis attack reduced,no recurrence had been reported.ConclusionMedical treatment failure is common in gout due to side effects of the drugs and limited recognition of the disease.The incidence of acute attacks can be decreased and the systematic uric acid load can be reduced as well.And available surgical interventions are the most efficient approach to improve the appearance and the joint function.So,once the tophus has formed in or around the joints,surgical treatment should be performed as soon as possible to prevent joints from further destruction.