Timing of intra-lesion shaving for surgical treatment of chronic tophus.

OBJECTIVES: Gouty arthritis results from the deposition of monosodium urate crystals in synovial spaces. The literature shows that a tophus may require surgical treatment to improve cosmesis or function, to alleviate pain, to eradicate sinus drainage or to remove large urate deposits. However, forceful curettage to remove tophus particles embedded in the thin attenuated skin flap may compromise blood circulation and cause other complications. This series presents the experience of the authors in performing intra-lesion shaving during the surgical treatment of tophus patients.

METHODS: This study analysed 147 surgical procedures performed in 108 patients with chronic tophus at a single hospital during November 2000 to July 2010. All patients underwent a soft-tissue shaver-assisted intra-lesion excavating technique developed by the authors. Bimanual palpation of the skin was performed to avoid trauma to the skin envelope. The shaving technique proved to be a simple and efficient method of reducing the total urate burden in the body.

RESULTS: Compared to conventional surgical treatment, the shaver technique is a safer and more effective option for treating tophus lesions. In this series, wound cultures were positive in 18.4% of operations. Patients with positive wound cultures and chronic renal impairment had significantly longer hospital stays compared to patients with negative wound cultures and patients without chronic renal impairment (P=0.0019 and P=0.0045, respectively); patients with C-reactive protein (CRP)<5 mg l(-1) and white blood cell (WBC) count<10,000 μl(-1) had significantly shorter hospital stays compared to patients with CRP>5 mg l(-1) and WBC>10,000 μl(-1) (P=0.0002 and 0.006, respectively). The upper extremities group and the upper-lower extremities group had significantly shorter hospital stays compared to the lower extremities group (P=0.001 and P=0.0014, respectively).

CONCLUSIONS: Medical treatment to control hyperuricaemia is important for reducing the risk of an acute attack of tophus formation. However, the data in this series show that surgery should be performed before the skin becomes ulcerated and before the tophus mass becomes infected. The proposed shaver technique markedly reduces tophus of the extremities with minimal surgical complications.