A 50-year-old man with a 10-year history of gout presents with a large, firm, painless tophi over the olecranon and first MTP joint with destruction of the joint surface on X-ray. His serum uric acid is 11 mg/dL. Which statement about orthopedic management is CORRECT?
- A Surgical excision of tophi alone resolves the problem permanently without urate-lowering therapy
- B Colchicine is the definitive long-term treatment for tophaceous gout
- C Joint arthroplasty is absolutely contraindicated in gout patients
- D Urate-lowering therapy (allopurinol/febuxostat) to target serum urate <6 mg/dL is the primary treatment; surgery only for complications ✓
Explanation
The primary treatment of tophaceous gout is medical: urate-lowering therapy (ULT) with allopurinol (target serum urate <6 mg/dL, or <5 mg/dL in severe tophaceous disease) to dissolve urate crystals over months to years. Surgical excision of tophi is reserved for complications: ulcerating/infected tophi, nerve/tendon compression, persistent mechanical disability, or failure to respond to ULT. Surgery alone without ULT results in recurrence. Colchicine prevents acute attacks but does not dissolve tophi. Joint arthroplasty can be performed in gout but infection rates are higher and ULT should be optimised preoperatively.
Reference: Maheshwari Essential Orthopaedics, 6th ed.
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Written and medically reviewed by the StethoPrep medical team.