Orthopaedic Case Study: Tophi Eroding Through the Skin
Mr. Lee, 38, noticed swelling in his left big toe over 20 years ago. But at the time, I didn't know I had gout, and my family thought it was rheumatism. Consequently, he never sought formal medical attention or took medication until five or six years ago when he started developing prominent lumps all over his body, including his fingers, toes, elbows, and knees. These subcutaneous lumps are actually tophi. A few years ago, the tophus on his left foot even eroded through the skin, causing a severely infected wound that took four months to heal. His main current problem is joint deformity, and he has severe tophi in multiple joints, which affects his daily mobility. The doctor has already treated some of the tophi with minimally invasive surgery, but the tophi in other areas seem to have accumulated over many years and may eventually erode through the skin. He may need further minimally invasive surgery in the future.
Three Levels of Tophi Severity
Dr. Chan Pak-hin, an orthopedic specialist, pointed out that many people mistakenly believe that gout only affects the big toe. In fact, the mild pain is just the prelude. It is easier to control the condition at this stage, but if it is not controlled in time, it may develop into challenging gout, eventually affecting all joints.
As for Mr. Lee, the most challenging part is the risk of spontaneous infection and skin rupture at any time, said Dr. Chan.
In reality, the worsening of the condition in both cases was due to different reasons, but the key to future management is inseparable from tophi.
Gout affects about 1% of the population in the Asia-Pacific region, and 5%-6% of the population in Hong Kong suffers from the condition, with a higher prevalence in men. It is largely related to genetics and dietary habits. The initial symptom of gout usually affects a single joint, most often the big toe on one side. For example, people who rarely drink alcohol should be particularly cautious if they attend a celebratory banquet and drink too much, causing joint redness and swelling, or if they occasionally experience joint redness and swelling after eating seafood.
According to the 2012 Gout Treatment Guidelines issued by the American College of Rheumatology, the first step to effectively treat gout is to adopt a low-purine diet. This includes avoiding red meat and offal, shellfish such as oysters, mussels, clams, shrimp, and general prawns. Fish such as sardines, tuna, and other scaleless fish should also be avoided as much as possible. Vegetables such as spinach, cauliflower, bean sprouts, wolfberries, snow peas, and sugar snap peas are recommended to be consumed no more than one catty (approx. 600g) per week.
The second step is medication. Dr. Chan said: Generally, for a first attack, patients can take colchicine, a uric acid-lowering drug, combined with a non-steroidal anti-inflammatory drug (NSAID), which can improve the condition in about five to seven days. However, strict attention must be paid to diet afterward, and regular follow-up blood tests are necessary. If follow-up shows that uric acid levels remain high, according to the American College of Rheumatology guidelines, the patient needs to receive long-term drug treatment, usually for three months, until the uric acid level drops to the ideal level.
However, if the condition is not well controlled, 10% to 30% of patients will develop chronic gout and tophi. Tophi are hard lumps formed by the accumulation and deposition of uric acid in the joints over many years. They are generally divided into three levels, as summarized in the table below:
Dr. Chan Pak-hin stated that according to the American College of Rheumatology guidelines, Level 3 patients need to take xanthine oxidase inhibitors, a uric acid-lowering drug, for at least three to six months. However, most severe cases cannot be completely resolved by medication alone, and ultimately, minimally invasive surgery to remove the tophi must be considered.
Traditionally, if tophi eroded through the skin, open surgery was used to remove the stones, but the wound was large, and because the patient's affected area had accumulated tophi for many years, the healing ability of the surrounding tissue was poor, so the wound might take weeks to months to heal. In recent years, the introduction of minimally invasive arthroscopic tophi removal surgery only requires two small incisions. A few-millimeter-diameter arthroscopic instrument, including a camera and a shaver, is inserted, allowing the doctor to directly monitor the removal of the tophi.
The advantages of minimally invasive surgery are that the wound is small and can heal in about two weeks. Second, the tophi causing the damage can be removed directly under visual guidance, immediately reducing the number of tophi in the affected area, and also reducing the inflammation of the synovial membrane around the joint, thereby reducing the risk of recurrence.
In summary, if severe gout causes comprehensive damage to the knee joint, protecting the cartilage with glucosamine and hyaluronic acid can be considered to prevent secondary degeneration. For cases requiring surgical removal of tophi, minimally invasive surgery is a preferred option.
