What is the surgical treatment for a patient with a history of gout and periarticular tophi (uric acid deposits) approximately 5cm in diameter located along the lateral malleolar area?

Surgical Treatment of Large Periarticular Tophi at the Lateral Malleolus

Medical therapy with aggressive urate-lowering therapy (ULT) should be the primary treatment approach for large tophi, but surgical excision is indicated when tophi cause mechanical impairment, nerve compression, skin ulceration, infection, or when optimal medical therapy has failed to achieve resolution. 1, 2, 3

Primary Medical Management Strategy

Initiate aggressive pharmacologic ULT immediately as the cornerstone of treatment for patients with subcutaneous tophi, regardless of size 4:

• Start allopurinol as first-line therapy at ≤100 mg daily, titrating upward every 2-5 weeks until achieving target serum urate <0.30 mmol/L (5 mg/dL) 1, 2
• The standard 300 mg allopurinol dose frequently fails to achieve target levels; doses above 300 mg are often necessary 1, 5
• Febuxostat is the alternative if allopurinol is contraindicated or not tolerated 1, 2
• Initiate flare prophylaxis with colchicine (up to 1.2 mg daily) when starting ULT to prevent acute attacks during crystal mobilization 1, 2

Monitor serum urate every 2-5 weeks during titration, then every 6 months once target is achieved 1, 2

Indications for Surgical Intervention

Surgery should be considered in the following specific circumstances 4, 2, 3:

• Nerve compression or entrapment neuropathy causing neurological symptoms 3
• Mechanical impingement severely limiting joint range of motion or causing joint instability 3
• Skin ulceration or infection that cannot be controlled medically 3, 6
• Impending or actual joint destruction despite medical therapy 3, 6
• Failure of optimal medical therapy to achieve tophus resolution after sustained target serum urate levels 3
• Contraindication to all available ULTs (rare circumstance) 3

A 5cm tophus at the lateral malleolus would likely cause significant mechanical impairment of ankle function and carries high risk for skin breakdown, making it a reasonable surgical candidate if medical therapy fails or complications develop 3, 7.

Surgical Approach and Outcomes

Surgical excision or debulking has demonstrated favorable outcomes in published series 3, 7:

• Seven surgical series published between 2002-2014 reported generally positive outcomes without major post-surgical complications 3
• A series of 14 patients (12 with upper extremity, 3 with lower extremity tophi) showed 100% patient satisfaction with no complications or recurrence at mean 3-year follow-up 7
• Surgical intervention can provide immediate pain relief and functional improvement 7, 6, 8

Critical surgical considerations:

• Surgery addresses the mechanical problem but does not treat the underlying hyperuricemia 3
• ULT must be continued indefinitely post-operatively to prevent recurrence 1, 2
• Wound healing may be compromised in gouty tissue; infection control is essential 6

Advanced Medical Therapy for Refractory Disease

If tophi fail to resolve despite optimal oral ULT, consider pegloticase before surgery 1:

• Pegloticase is strongly recommended for nonresolving subcutaneous tophi despite optimal oral therapy 1
• Biweekly pegloticase achieved tophus resolution in 40% versus 7% on placebo (moderate-certainty evidence) 1
• This represents a medical alternative to surgery for refractory cases 1

Critical Pitfalls to Avoid

Never discontinue ULT after surgical removal of tophi, as this leads to recurrence of both tophi and gout flares 1, 2

Do not rely solely on surgery without addressing the underlying hyperuricemia through sustained ULT 3

Avoid premature surgery before attempting aggressive medical therapy with target serum urate <0.30 mmol/L (5 mg/dL) for adequate duration 1, 2

Do not accept subtherapeutic allopurinol dosing (e.g., stopping at 300 mg) when higher doses are needed to achieve target 1, 5