Case in Point Surgical Management of a Large, Gouty Tophus

Scott Glassburn, DPM

This patient, who could not tolerate medical therapy for his chronic , eventually consented to surgery to remove a tophus on his left foot that was severely affecting his quality of life.

out is a metabolic disease Initial Exam plantarly. It extended distally to the that occurs when excess A 56-year-old man was referred to interphalangeal of the hallux amounts of cir- a VA podiatry clinic by his primary and proximally toward the plantar Gculating in the blood crys- care provider (PCP). He presented medial arch, approximately mid-shaft tallize and subsequently deposit in with a large, indurated mass about of the first metatarsal bone. or soft tissue. his left first metatarsophalangeal Radiographs revealed a large, con- is the condition most often associ- (MTP) joint (Figure 1). The lesion tiguous, soft tissue density about the ated with an acute gouty attack or, in was not focally tender, but its girth first MTP joint as described (Figure chronic states, with the formation of hindered the patient’s ability to wear 2). There were no lytic osseous le- tophi.1,2 In all cases, the demonstra- shoes. The patient had similar masses sions or areas in proximity with tion of monosodium urate crystals in and symptoms of intermittent pain diminished bone density. Examina- the joint or surrounding soft tissues and swelling in multiple other joints, tion revealed excellent pedal pulses is sufficient to make a definitive diag- including his hands, knees, wrists, (dorsalis pedis, +2/4; posterior tibial, nosis of gout.3–5 and elbows. These lesions had devel- +2/4) bilaterally with three-second In this article, we describe the case oped over a six-year period prior to capillary refill to all digits. Tactile and of a patient with chronic hyperuri- his initial clinic presentation. vibratory sensations were intact and cemia who presented to a VA podi- The patient was being treated by normal distally, bilaterally, and sym- atry clinic with an unusually large, his PCP for hypothyroidism (which metrically. gouty tophus. While management his PCP described as “borderline of his condition through medica- myxedema”) and hyperlipidemia. Treatment course tion, dietary changes, and other life- His PCP also previously had detected Alternative treatments were discussed style modifications was attempted, hyperuricemia and diagnosed him with the patient, including excision surgical intervention eventually was with polyarticular tophaceous gout, of the mass, but the patient declined necessary. Among the other notable for which the PCP prescribed a regi- surgery. He was advised to refrain features of this case was the fact that men of allopurinol. The patient could from eating purine rich foods and to he was diagnosed with chronic renal not tolerate this medication, however, use shoes that provided extra depth failure and nephritic syndrome after and discontinued the regimen after and width to accommodate the defor- developing multiple tophi, whereas three months of chronic nausea. Col- mity as much as possible for his work such conditions usually are diag- chicine was prescribed but also was (as a plumber) and casual activities. nosed before any gouty symptoms not tolerated by the patient. The patient returned to our clinic manifest. The primary lesion of concern was two years later. He had taken an the tophus surrounding the left great early retirement since the gouty toe. Upon physical examination at tophi and debilitating pain made it Dr. Glassburn is the chief of the podiatry section of the surgical service at the Huntington VA Medi- the initial clinic visit, the lesion was impossible to continue his work. cal Center, Huntington, WV. observed to extend medially and At this visit, the lesion on the first

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around the first MTP joint had in- creased in lucency. A modest, hallux, valgus deformity and crowding of the lesser digits was developing second- ary to the tophus. The patient was urged to consider excision, but he again declined surgi- cal intervention. (Up to this point in his life he had never been admitted to a hospital nor had surgery of any Figure 1. The patient’s left foot at initial kind.) We recommended local wound (2004) presentation to the podiatry clinic, care measures and followed up with showing a large, indurated mass about the him monthly to monitor the integrity first metatarsophalangeal joint. Figure 3. The patient’s left foot in 2007, of tissue overlying the tophi. In the showing a markedly larger, denser, and months that followed, the patient de- more indurated lesion, with atrophy and veloped other small ulcerations. distension of the overlying soft tissues. Results of laboratory testing dur- ing this period revealed elevated blood urea nitrogen, uric acid, and creatinine levels. Based on these find- ings, the patient was referred to a ne- phrologist, who made a diagnosis of nephritic syndrome and chronic renal failure. The patient also was screened for lead toxicity, the results of which were negative. As the patient could not tolerate allopurinol or colchicine, and he continued to defer recom- mended procedures, we referred him Figure 2. Radiographic images of the pa- to an orthotist for molded accommo- tient’s left foot at initial (2004) presenta- dative shoes. tion to the podiatry clinic, showing a large, One year later, the patient re- Figure 4. Radiographic images of the pa- contiguous, soft tissue density about the tient’s left foot in 2007, showing a larger, turned to the clinic, unable to wear first metatarsophalangeal joint. denser soft tissue mass, with increased the prescribed shoes and otherwise lucency in the bone around the first meta- to find relief. The patient agreed to tarsophalangeal joint. A modest, hallux, and was scheduled for an outpatient MTP joint was observed to be mark- valgus deformity and crowding of the procedure to surgically remove his to- edly larger, denser, and more indu- lesser digits was developing. phus. Results of preoperative labora- rated (Figure 3). The soft tissues tory testing were unremarkable and overlying the lesion were becom- clearance was obtained from his PCP. ing atrophic and distended. The pa- Concerns about tissue compromise, tient was unable to wear any shoes tal analysis. The results of cultures possible wound complications, de- other than oversized house shoes or were negative. Crystal analysis under formity of the first MTP joint, and slippers. a polarized microscope confirmed the crowding of the digits were discussed A small ulceration was present presence of needle-like, negatively bi- with the patient and his PCP. The on the proximal plantar margin of refringent urate crystals. patient provided informed consent the mass. A considerable amount of Radiographs at this time revealed to perform a Keller arthroplasty in- chalky material was curetted from the a larger soft tissue mass in the area volving resection of the base of the wound, and a sample of this material described (Figure 4). The mass had proximal phalanx and Kirschner-wire was cultured and submitted for crys- increased in density and the bone stabilization of the hallux.6

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concerns about wound complica- tions. When the wound was checked the next morning, a modest hema- toma was discovered. The drain was removed, the hematoma evacuated, and the wound irrigated at bedside. A thick compression dressing was then reapplied. The patient was discharged on the Figure 5. The patient’s left foot immedi- Figure 6. Keller arthroplasty of the pa- second postoperative day after an- ately before surgery (2008), showing pro- tient’s tophus, with use of a Steinmann pin other wound check. At that time, the gression of the gouty tophus. to stabilize the joint and surrounding soft overlying skin flap was intact and vi- tissues. able with good capillary refill. There was no drainage and no signs of in- Surgical procedure fection. The patient was discharged One month later, under regional an- The lesion measured roughly 2 cm with a regimen of cephalexin and hy- esthetic with intravenous sedation, x 6 cm x 8 cm. The densely packed drocodone. the patient underwent excision of the tophaceous material had disrupted The patient adhered to the post- gouty tophus and stabilization of the much of the medial first MTP joint operative instructions and remained hallux on the patient’s left foot (Fig- capsule. Approximately 60% of the non–weight bearing until his sutures ure 5). “Time out” protocols were fol- bulk of the lesion was removed piece- were removed on the 14th postop- lowed to ensure that proper patient, meal using sharp and blunt dissec- erative day. At that time, there was a side, and site of procedures were car- tion and curettement. Pulsed lavage 1.5-cm portion of the dorsal wound ried out. proved helpful in loosening adher- that dehisced. A sterile compression A dorsomedial incision was ef- ent tophaceous deposits from healthy dressing was applied for a subsequent fected over the mass. Immediately capsular tissues. 14 days. Radiographs taken on the deep to the skin, tophaceous mate- Due to disruption of the joint cap- 28th postoperative day confirmed rial was encountered. There was very sule and persistent valgus deformity, good alignment of the joint and good little subcutaneous tissue found over a Keller arthroplasty was performed. reduction of the soft tissue mass. the lesion, as it had become displaced The articular surfaces of the joint Four weeks after surgery, the wound by the mass. The tophus was com- were white with tophaceous deposi- was entirely closed and the pin was prised of dense, chalky material with tion. Tophaceous material and bone removed. The patient was instructed irregularly traversing septal elements. specimens were submitted to pathol- that he could begin to bear weight, to Contrary to expectations, the margins ogy and for crystal analysis. A Stein- tolerance, on his foot using a DARCO of the tophus were not distinct or en- mann pin was used to stabilize the shoe (DARCO International, Inc., capsulated. The mass was contigu- joint and surrounding soft tissues Huntington, WV). ous, and tissue planes were difficult (Figure 6). We considered perform- At six weeks, the patient was al- to identify between the skin and the ing a skin plasty with the resultant lowed unrestricted activity in ac- joint. Care was taken to avoid deglov- redundant tissue, but the tissue had commodative shoes. Two months ing the overlying skin and to avoid been so compromised by the mass after surgery (Figure 7), his foot had disrupting neurovascular structures that we risked compromising the healed to the point at which he could to the hallux. The margins dorsally, skin flap. Considerable dead space comfortably wear casual, lace-up proximally, and distally were ascer- remained and a small Penrose drain shoes. tained, but the plantar margins could was placed in the proximal plantar One notable complication that not be visualized through the dorsal border of the wound. A thick com- arose approximately two months after incision. A plantar medial incision pression dressing was then applied. the patient returned to shoes is that was made to visualize the plantar and the redundant tissue formed a pedicle lateral extent of the tophus, which re- Postoperative course proximally. The cleft of this redun- vealed some invasion to the adjacent Following the procedure, the patient dant skin developed an intertrigo that plantar fat pad. was admitted to the hospital due to resolved with topical astringents and

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state of hyperuricemia exists.7,8 Tophi phaceous gout—even though the are relatively indolent but often be- renal disease was not diagnosed until come a nuisance due to their volume after his gout had progressed to the or mass. Common sites of tophi are chronic stage. It is more often that fingers, ears, and prepatellar and olec- gout will manifest after such primary ranon bursae. Pressure areas on the conditions are diagnosed. Lead toxic- Achilles tendon and ulnar surface of ity also was suspected as a contrib- the forearm also are common. This uting factor in this patient, but his patient’s case is particularly interest- lead levels were within normal limits Figure 7. The patient’s left foot eight weeks ing due to the dramatic presentation when tested around the time of his after surgery. and course. nephrology referral. Radiographs are very useful in In terms of the surgical approach, tracking the progression of topha- we could have been more aggressive antifungals. We explained to the pa- ceous gout: The density of the tophus in the volume of tophus that we ex- tient that a skin plasty to remove this can be appreciated at its proximal, cised from this patient. Additionally, redundant skin could be performed distal, medial, and lateral margins. better incision planning might have in the future. Similarly, radiographs are helpful in allowed better access to the mar- patients with intermittent gout to gins of the lesion and a possible skin About the Condition evaluate bony erosions or joint de- plasty to be performed to remove re- A hyperuricemic state can be caused struction wrought by the acute in- dundant tissue. by overproduction or underexcretion flammatory processes. In defense of the more conserva- of uric acid. Overproduction of uric Treatment of gout usually is aimed tive choices, however, the skin over- acid can be primary due to genetic at relieving the acute exacerbation, lying the mass was compromised defects that result in hypoxanthine- with colchicine and nonsteroidal anti- preoperatively by the pressure and guanine phosphoribosyltransferase inflammatory drugs being prescribed bulk of the lesion (ulcerations had deficiencies or phosphoribosylpyro- most often for acute gouty episodes. developed). Additionally, the skin phosphate synthetase overactivity. Periarticular and intra-articular injec- flap was fairly devoid of subcutane- Secondary overproduction often is tions of soluble corticosteroids also ous tissue to offer vascular support to caused by excessive dietary intake of can be helpful (after a peripheral lido- the dermis, which would have been purine rich foods, but it also may be a caine nerve block) in diminishing the the case even if more clever flaps result of myeloproliferative or hemo- intensity and duration of the acute at- had been devised at the outset. The lytic disorders. Underexcretion often tack, especially if injected early in the hematoma that formed in the dead is due to renal insufficiency or hypo- acute episode. space postoperatively would have thyroidism; it may also be secondary When chronic hyperuricemia is di- been just as likely. Due to poor defi- to dehydration, use of diuretics, or agnosed, allopurinol and probenecid nition of anatomy from the density insulin resistance. Lead toxicity (ne- often are used. Allopurinol is used fre- of the lesion, we were hesitant to re- phropathy) is another known cause.2 quently for tophaceous gout and, if move more of the tophus—especially Uric acid in a supersaturated so- tolerated, can reduce the size of tophi along the distal lateral margin of the lution (such as serum) can form a over time. Dietary counseling to re- lesion—for fear of causing vascular precipitate of sodium urate crystals. duce intake of purine rich foods also embarrassment or neuropraxia to the The deposition of monosodium urate is important. When medical therapy is hallux. crystals may be perceived as a mecha- insufficient or unable to be tolerated, Even without severe joint destruc- nism of lowering—or a physiologic as illustrated in this case study, surgi- tion, the Keller arthroplasty was a attempt to maintain—serum levels cal intervention may be considered. good choice as an adjunct to improve of uric acid. Acute gouty attacks are the joint position postoperatively. The the result of intense inflammation Revisiting the case Kirschner-wire fixation further stabi- aroused by precipitates of monoso- In the case of the patient presented lized the soft tissue and diminished dium urate that form during an in- here, hypothyroidism and renal pa- stress to the flap. Pulsed lavage also termittent state of hyperuricemia. thology both likely contributed to proved useful in removing some sec- Gouty tophi develop when a chronic his hyperuricemia and chronic, to- tions of the lesion. ●

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