Surgical Excision of Large Periarticular Tophi in Gout
Instrument Used: Arthroscopic Shaver
The arthroscopic shaver is the primary instrument used for surgical excision of large periarticular tophi, as demonstrated in contemporary surgical series. 1
Technical Details of the Shaver Technique
The shaver technique involves using an arthroscopic shaver device to mechanically debride and remove tophaceous deposits from periarticular tissues 1
This approach allows for controlled removal of chalky white monosodium urate crystal deposits while preserving surrounding viable tissue 2
The technique is particularly effective for removing chronic tophaceous masses that have not responded to urate-lowering therapy (ULT) 1
Surgical Outcomes and Timing Considerations
Surgery should be performed before tophus infection develops, as this significantly impacts outcomes. 1
Patients without preoperative tophus infection have shorter hospital stays (8.6 vs 12.7 days) and faster wound healing (16.3 vs 22.7 days) compared to those with infected tophi 1
Upper extremity lesions demonstrate better clinical outcomes than lower extremity lesions, with shorter hospital stays and wound healing times 1
Factors such as age, sex, body mass index, renal function, or serum uric acid levels do not significantly affect surgical outcomes 1
Clinical Indications for Surgical Intervention
Surgery should be considered when tophi cause urgent complications or when medical management has failed despite adequate ULT. 3
Specific indications include:
- Impending or established infection of the tophus 1, 3
- Ulceration with skin breakdown 3
- Entrapment neuropathy from mass effect 3
- Joint instability or severely limited range of motion 3
- Significant functional impairment affecting quality of life 2, 3
- Risk for permanent joint destruction 3
- Contraindication to all available urate-lowering therapies 3
Post-Surgical Management
All patients must be placed on urate-lowering therapy (typically allopurinol) following surgical excision to prevent recurrent attacks 2
For tophaceous gout, target serum uric acid below 5 mg/dL (300 μmol/L) rather than the standard target of <6 mg/dL 4
Histopathological confirmation of excised tissue as gouty tophus should be obtained 2
Expected Outcomes
Surgical series report generally positive outcomes without major post-surgical complications 5, 3
Patients typically achieve symptom relief and increased mobility within 6 weeks post-operatively 2
Long-term follow-up (mean 3 years) shows high patient satisfaction with no tumor recurrence when combined with appropriate medical management 5
Critical Pitfall to Avoid
The most important pitfall is delaying surgery until infection develops. 1 Once tophus infection occurs, surgical outcomes are significantly worse with prolonged hospital stays and delayed wound healing. Early surgical intervention for symptomatic tophi that are not responding to medical management yields superior results compared to waiting until complications develop.