In 10 per cent of patients with gout, tophi form; these may destroy skin, tendons, ligaments, and the skeletal structures. Since the disease may ultimately disable the musculoskeletal system, if improperly treated, the management of these patients should be the combined responsibility of the internist and the orthopaedic surgeon.
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Early diagnosis and prompt treatment can prevent severe crippling. In patients in whom the disease has been neglected tophaceous destruction of musculoskeletal structures may be helped by carefully selected surgical procedures.
The pathological process is one of invasion and destruction of skin, ligament, tendon, cartilage, and bone by deposition of urates. This process is accompanied by an acute or chronic inflammatory response at the site of involvement. Lesions may be encapsulated in bursae and subcutaneous tissue and infiltrative in skin, tendon, and bone.
Tophi may form rapidly or slowly and physical properties vary from semiliquid to inspissated, chalk-like deposits. The distribution of lesions is primarily distal in the extremities with a predilection for the extensor surfaces. Blood vessels may be involved in the process to a moderate degree, but nerves and muscles are apparently affected by pressure phenomena rather than invasion or deposition of urates.
We believe surgical intervention is warranted in the following conditions found in chronic tophaceous gout: (1) when tophi are unsightly: (2) when tophi are painful; (3) when tophi interfere with tendon function; (4) wherm tophi threaten to cause skin necrosis and ulceration; (5) when tophi have ulcerated or sinuses are present: (6) when tophi encroach upon nerves causing symptoms of compression; (7) when joints are being destroyed and are painful; and (8) when the total amount of urates in the body can be lowered by excision of readily accessible large tophi.
Sodium urate and uric acid seem to possess bacteriostatic properties so that sepsis is usually mild and well localized when present.
Circulation may be impaired by tophi when distension of the tissues is marked, although the skin survives remarkably well until late in the process. Arteriosclerosis is commonly present in the lower extremities in the older patients. These factors demand specialized surgical technique.
The pneumatic tourniquet may be used in the upper extremity, but should be used cautiously in the lower extremity. Local tourniquets should not be used about fingers or toes.
General anaesthesia is preferable to local anaesthesia except for minor excisions of superficial tophi. Distension of tissues with the local anaesthetic agent may impair the blood supply and cause necrosis of skin.
Incisions in general should parallel the blood supply of the part. Counter-incisions in the fingers and toes should be avoided as necrosis of the intervening skin may result. Sharp dissection is preferred when it is feasible, but curettage may be done in infiltrative lesions to remove the maximum amount of urates while preserving essential structures.
Gentle handling of tissues is necessary to preserve the blood supply. Wounds should be irrigated to prevent necrosis of tissue from drying and to mechanically aid in removal of the tophi.
Resection of joints, arthroplasty, and arthrodesis of painful joints may lessen pain and improve function to a limited degree. Curettage or partial resection of tendons may help preserve function.
Skin-grafting may hasten healing of ulcerated lesions after removal of the gouty deposits when granulation tissue appears.
Infection is not a serious problem and the general principles of treating infections apply to gout with addition of the medical management peculiar to gout.
Minimal suturing of wounds is advisable in order to preserve blood supply and to allow escape of liquified deposits following surgery when removal of the tophus is incomplete.
Pressure dressings and splints minimize dead space, help prevent hematomata, and put the parts at rest so that healing may occur.
Prolonged splinting is to be avoided as ankylosis may occur.
Amputation of toes may be necessary, but every effort should be made to preserve the fingers.
A definite plan of preoperative and postoperative medical management helps to prevent complications and acute attacks following surgery.
Department of Orthopaedic Surgery, Northwestern University Medical School, Chicago; Orthopaedic and Rheumatology Services of the Veterans Administration Hospital, Hines