A 60-year-old man with tophaceous gout has a chronic gouty tophus over the first MTP joint causing skin breakdown and secondary infection. His serum urate is 9.2 mg/dL despite allopurinol 300 mg/day. The orthopedic intervention most appropriate for the infected tophus with impending skin loss is:
- A Increase allopurinol dose — this alone will resolve the infected tophus
- B Urgent surgical debridement and tophectomy with wound closure ✓
- C Intra-articular corticosteroid injection
- D Ice application and elevation only
Explanation
When a tophus ulcerates with skin breakdown and secondary bacterial infection, surgical debridement and tophectomy (removal of the tophaceous deposit) is indicated to control infection, achieve wound closure, and prevent spread to underlying bone or joint. Medical urate-lowering therapy (ULT) is the long-term standard to reduce tophus burden and prevent recurrence, but it cannot rapidly resolve an acute infected, ulcerated tophus with skin compromise. Increasing allopurinol during an acute flare can actually worsen the attack by mobilising urate crystals. Corticosteroid injection is contra-indicated in an infected lesion.
Reference: Maheshwari Essential Orthopaedics, 6th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.