Surgical Management of a Large, Gouty Tophus

Case in Point Surgical Management of a Large, Gouty Tophus Scott Glassburn, DPM This patient, who could not tolerate medical therapy for his chronic gout, 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 joint of the hallux amounts of uric acid 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. joints or soft tissue. Hyperuricemia 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 Continued on page 14 12 • FEDERAL PRACTITIONER • MARCH 2010 CASE IN POINT Continued from page 12 around the first MTP joint had increased 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 surgical 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 recommended 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 14 • FEDERAL PRACTITIONER • MARCH 2010 CASE IN POINT concerns about wound complications. When the wound was checked the next morning, a modest hematoma 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.

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