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Patients with severe tophaceous gout who are at risk for complications -- including permanent joint destruction -- and who have not responded to medical management may benefit from surgery, a literature review suggested.

Among patients who could be considered for surgery are those with refractory disease, poorly controlled pain, nerve entrapment, recurrent infection, skin ulceration, or a discharging sinus, according to , and colleagues from Harvard University and Beth Israel Deaconess Medical Center in Boston.

In addition, patients with functional impairment, joint instability, or significant impairments of joint motion also might benefit, the researchers reported in

"Depending on their anatomic location, tophi have the potential to cause irreversible joint damage with bony destruction. Tophi can also entrap nerves, causing compressive neuropathy, such as carpal tunnel syndrome or radiculopathy. Superficial tophi are also susceptible to infection, especially if the overlying skin is ulcerated," they explained.

The treatment of gout relies on urate lowering therapy, with a typical serum urate target being below 6 mg/dL. Options include the xanthine oxidase inhibitors allopurinol or febuxostat (Uloric) or in refractory cases, the recombinant uricase enzyme peglioticase (Krystexxa).

But treatment remains imperfect, with obstacles including inadequate dosages and poor adherence. Moreover, "many gout patients have complex comorbidities and medication profiles, making medical management challenging and even prohibitive in some circumstances," Kasper and colleagues wrote.

Surgery has been used since ancient times for gout, but few studies have addressed its current role since the advent of effective urate lowering therapy. Therefore, the researchers conducted a systematic literature review in which they found no controlled clinical trials but identified seven retrospective case series of surgery that included more than 300 patients.

"The reported outcomes were generally positive with restoration of function, while the most common adverse outcome was delayed wound healing," the researchers commented.

In , a retrospective review of 45 patients, the most common reason for surgery was for control of sepsis deriving from infected tophi. More than half of patients experienced delayed wound healing, but 47% had no complications following the surgery.

The authors concluded that there was a relatively high rate of complications when the indication for surgery was sepsis. They also observed that medical therapy had been inadequate, with more than two-thirds of patients having hyperuricemia and fewer than one-third having taken allopurinol.

In of 147 patients treated with a shaver technique, extended hospitalizations were seen in patients who had renal impairment, elevated C-reactive protein, positive wound cultures, and white blood cell counts above 10,000 cells/mL. The authors of this study stated, "The data in this series show that surgery should be performed before the skin becomes ulcerated and before the tophus mass becomes infected."

A included 28 men with repeated gout attacks of the first metatarsophalangeal joint. A total of 15 chose arthroscopic intervention and then medication, while 13 received urate-lowering therapy alone.

Both groups improved, with fewer gout attacks and improved function, but the surgery group had significantly better results, according to the study authors. They also noted that all of the patients who had only medical treatment continued to have serum uric acid levels above 6 mg/dL at follow-up despite the use of urate-lowering treatment.

"In the published literature, the best reported surgical outcomes seem to be for patients who have failed or are intolerant of medical treatment for tophaceous gout, but have not yet developed substantial loss of function, infection, or skin ulcerations," Kasper and colleagues wrote.

They noted that the number of patients requiring surgery today should be small, because of the availability of effective medical therapies and a better understanding of the prevention of adverse events.

Based on their own clinical experience and the literature, they offered advice on the preferred surgical approach according to the consistency of the tophus and the extent of joint involvement.

For instance, if the tophus material is soft, an incision with aspiration can be done. If the soft lesions are within joints or tendons, tophectomy can be done, but with cartilaginous destruction of the surface of the joint, complete joint resection may be needed.

If large spaces between articulating surfaces remain after resection, arthroplasty or arthrodesis using wire or cement can be used. And in rare instances, such as with severe peripheral vascular disease or deformity resulting from bony destruction, amputation may be required.

Kasper and colleagues concluded, "Prospective studies with identified indications and outcomes are needed to better guide clinicians with respect to which patients with tophaceous gout are appropriate candidates for surgery."

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