Treatment of tophaceous gout: When medication is not enough.

Abstract

To review the literature concerning surgical intervention of tophaeceous gout and propose clinical circumstances for when it may be considered. Tophi develop in approximately 12-35% of patients with gout. Tophaceous disease is usually preventable given the availability of effective urate lowering therapies (ULT) including allopurinol, febuxostat, probenecid, lesinurad, and pegloticase. Despite medical therapy, there remains a subset of patients who develop significant complications of tophi including infection, ulceration, and entrapment neuropathy. Tophi in close proximity to joints can cause joint instability, severely limited range of motion, and significant functional impairment. For the rare circumstance when a tophus is causing an urgent complication or if a patient has a contraindication to all available ULTs, surgery may be an appropriate option. This review summarizes the published experience with surgical interventions for tophaceous gout and offers recommendations for its consideration. Using Medline and Google Scholar, all available series of surgery for tophaceous gout were reviewed. Overall, 7 published surgical series were identified. In all, 6 of these 7 series were published between 2002 and 2014. The reported outcomes of surgical interventions for tophaceous gout were generally positive without major post-surgical complications. Although medical therapy with ULTs should be the first-line approach to tophaceous gout, surgery should be considered for the rare patient with impending or severe, debilitating complications including infections, entrapment neuropathy or those at risk for permanent joint destruction. In these selected clinical circumstances, surgical intervention for tophaceous gout may be appropriate.