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| Journal of the New Zealand Medical Association,
26-July-2002, Vol 115 No 1158
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A survey of indications, results and complications of surgery
for tophaceous gout
Sunil Kumar, Peter Gow.
Gout due to deposition of monosodium urate crystals in and
around the joints is a common metabolic
condition among the Polynesian population of New Zealand. The prevalence of gout
in Maori is 6.4% and in Europeans is 2.9%.1
Among Maori men prevalence of gout is 13.9% and European males 5.8%.
Hyperuricemia is significantly more common in Maori men (27.1%) than European
men (9.4%).1
Gouty tophi are one of the manifestations of prolonged,
uncontrolled hyperuricaemia and result from deposition of urate crystals in soft
tissues, tendon sheaths, bony prominences and
joints.2 This
causes joint destruction and deformities. Tophi can become inflamed, ulcerated
and infected, or cause pressure effects. The mainstay of management of
tophaceous gout remains medical therapy with the xanthine oxidase inhibitor,
allopurinol.3,4 It requires years of stringent
control of hyperuricemia before the tophi eventually disappear. Surgery remains
an uncommon but important therapeutic option for pain or pressure effects,
including entrapment neuropathy.5,6 Because of
complications it is rarely performed, with literature reviews limited to
isolated case reports.7-9
MethodsThis survey was undertaken to
look at the indications, results, and complications associated with surgery for
tophaceous gout. A retrospective analysis of all patients who underwent surgery
for tophaceous gout at Middlemore Hospital from July 1995 to July 2001 was
undertaken. Patients with gout who had surgery related to gouty tophi were
included in the study. Gout patients who had other surgical procedures were
excluded.
Details of associated medical conditions, indications for surgery, results, complications and functional outcomes were recorded. Serum creatinine and urate results were obtained from computerised laboratory records. Data on allopurinol use was obtained from medication history and by reviewing drug charts. Delayed wound healing was defined as any wound that failed to heal completely within one week of surgery. All complications leading to delayed wound healing were recorded up to six months following surgery. Results45 patients underwent surgery for
tophaceous gout, 60% of whom were referred by general practitioners, 22%
emergency department physicians and 18% by rheumatologists. The majority of
patients were males (89%), within the age range 41-60 years (66%) and of Maori
or Pacific race (54%).
Renal impairment (serum creatinine >0.11mmol/L) was the
most common associated medical condition (38%), followed by hypertension (27%),
ischaemic heart disease and/or congestive heart failure (20%), diabetes mellitus
(18%) and obesity (11%). Several patients had more than one medical condition.
Hyperuricaemia (urate >0.42mmol/L) was present in 68% of patients but 12% did
not have urate levels checked. Only 31% of patients were receiving allopurinol
prior to surgery. Indications for surgery were classified into four main groups:
sepsis control (infected/ulcerated tophi), mechanical problems, diagnostic
procedure and pain control (Table 1).
Table 1. Indications and results of surgery.
Delayed wound healing occurred in 53% of patients. The wound
healed within one week in 47%. The outcome was worse in patients who had
pre-existing sepsis (16/23, 70%) compared with patients who had
‘clean’ surgery (8/22, 36%). Delayed wound healing was more common
with foot surgery (50%) than to upper limb surgery (25%). The main complications
leading to delayed wound healing were slow healing without sepsis (33%), ongoing
sepsis requiring antibiotics and/or dressings (21%), a discharging sinus (17%),
ongoing sepsis requiring amputation (13%), failure of skin graft (8%), wound
haematoma (4%) and delayed union of bones at the osteotomy site (4%).
Functional outcome was measured as the ability to return to
the previous level of functioning and this was assessed at six months after
operation in 35 patients (78%). Two patients had died and eight patients could
not be located. Three out of 35 (9%) patients were left with minor disabilities
as a result of digit amputations. One patient developed complex regional pain
syndrome type 1 involving an arm and required pain management with reasonable
outcome. One patient had ongoing pain at the osteotomy site requiring regular
non-opiate analgesia. The other 30 patients had returned to their previous level
of functioning.
DiscussionGout is the most common
rheumatological condition in South Auckland, which has a large Maori and Pacific
Island population. The prevalence of tophaceous gout in New Zealand is unknown,
but it is commonly seen in clinical practice. The mainstay of treatment for
tophaceous gout is to lower the uric acid level with dietary and medical
therapy, but this may not be easy to achieve as several patients in South
Auckland present with severe disease, have several co-morbidities and have
difficulties with drug compliance. Our study confirms that surgery for
tophaceous gout is associated with a high complication rate and should be
reserved for special indications only. Lower extremity surgery had a worse
outcome compared to that in the upper extremity, which in some instances was due
to previously unrecognised peripheral vascular disease.
This study appears to include the largest number of patients
reported to have undergone surgical treatment for tophaceous gout. A literature
search using Medline and Cochrane Library databases from 1960 have failed to
reveal similar studies. Several case reports have been published showing
beneficial results for specific indications,5-9
but none was large enough to compare with our study, the size of which reflects
the prevalence of gout in the South Auckland population.
Management of gout remains a challenge in South Auckland for
reasons discussed earlier, but there also appears to be a lack of uniformity
among medical staff about when to start urate lowering agents, which may explain
why less than one third of our study patients were on allopurinol.
Recommendations we propose to improve care of gout patients include:
In conclusion, this study
demonstrated that surgery for tophaceous gout is associated with a relatively
high rate of complications, especially when sepsis is the main indication.
Patients in this study population had several associated co-morbidities which
would likely have contributed towards the high complication rate. Gout control
was poor as evidenced by the high rate of hyperuricaemia and inadequate use of
allopurinol at the time of surgery. More effort is required at primary care
level to obtain better control of gout so that the risk of tophus formation is
reduced and the need for surgery minimised.
Author Information:
Dr Sunil Kumar, Consultant Physician; Dr Peter Gow, Physician, Department of
Rheumatology, Middlemore Hospital, South Auckland.
Acknowledgement: We
thank Andrea Trowell for typing this manuscript.
Correspondence: Dr
Peter Gow, Middlemore Hospital, Private Bag 93311, Otahuhu, South Auckland.
Email: pgow@middlemore.co.nz.
References:
This article was corrected
23 August 2002 to reflect the Erratum, NZ Med J 2002;115: URL http://www.nzma.org.nz/journal/115-1160/155/
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