Surgical Reconstruction of Severe Tophaceous Gout in the Hand: A Customized Approach.

Tophaceous gout can represent a major problem for hand surgeons when it turns into aggressive nodules, spreading and destroying soft tissue and bone. The combination of ablative and reconstructive surgery may also be complex when the patient refuses amputations and multiple segments are involved. We present a difficult case, where a customized approach, chosen according to the different features of the osteoarticular and tendon involvement of fingers, adopted different solutions for the four affected rays. A patient suffering from severe gout arthritis with osteoarticular destruction in both hands refused amputations and was treated with several reconstructive procedures. After excision of the tophaceous deposits, a long bone autograft, two segmental cement spacers together with distal arthrodeses, and an osteoarticular allograft were used. Functional pinches were maintained in both hands, even at a 13-year follow up, with the allograft preserved and working. On the other hand, significant osteolysis and bone resorption in all the segments that had undergone stabilization was documented, producing extrusion of both cement and distal interphalangeal joint fusion screws. Pre- and postoperation range of motion, visual analogue scale, disabilities of the arm, shoulder, and hand score, and pinch strength tests showed reduced pain and improved function. A review of literature is presented in particular regarding different reconstructive approaches. Combining different techniques in the same hand can lead to successful osteoarticular reconstruction after tophi resection, above all to avoid amputation. However, long-term follow up shows that functional osteoarticular reconstructions seem to be more stable, whereas osteolysis may damage bone grafts used for arthrodesis and produce screw extrusion.