Surgical treatment of the chronic tophaceous deformity in upper extremities – the shaving technique

Abstract

Tophaceous gout is frequently directly related to the duration and the severity of hyperuricaemia. Conventional surgical debridement of the tophaceous lesions carries the risk of overlying skin necrosis. Life-long urate-lowering drugs have become the mainstay of primary treatment. However, surgical intervention may be necessary when the overlying skin becomes ulcerated and wound infection develops. This has become the impetus for new surgical treatment methods with less potential for morbidity. From November 2000 to July 2006, 32 patients with chronic tophaceous deposits involving their hands or elbows were treated surgically in our hospital. In this series, a soft tissue shaver device with a mini-incision technique was used to treat upper extremity tophaceous lesions. Multiple 5-mm skin incisions were made to allow direct access to the tophaceous mass. Intra-lesion shaving was done. A tourniquet aided reduction of intraoperative blood loss. Suction and irrigation were performed simultaneously while the shaver system was operating; the chalky deposits of sodium urate were thereby removed efficiently. No major complications were noted among these 32 patients. Using this shaver technique, each tophaceous lesion was removed in less than 15 min. Twenty-nine of these operations (80.6%) were performed for patients at the intercritical gout phase. Two patients suffered a recurrent acute attack of gouty arthritis within 12h after the operation. Symptoms were controlled by oral colchicine as well as nonsteroidal anti-inflammatory drugs (NSAID). Swelling at the operative site was usually evident for the first 10 days postoperatively, therefore posture drainage is advised. The shaver technique provides another option in the surgical treatment of tophaceous lesions. It prevents poor wound healing associated with tendon or joint exposure that often occurs after conventional enucleating procedures. The tophaceous lesions can be treated surgically at the intercritical gout phase. Also, the upper extremity group has a shorter hospitalisation period when compared with our preliminary study involving treatment of tophaceous deposits in the lower extremity. The shaver technique is worthy of consideration in the treatment of upper extremity chronic tophaceous patients.