A 45-year-old woman with gout presents to the orthopedic clinic with a chronic tophaceous deposit eroding through the skin overlying the first MTP joint with secondary infection. Her serum uric acid is 11.2 mg/dL. What is the orthopedic indication for surgical debridement/tophus excision in gout?
- A Any tophi detected on imaging regardless of symptoms
- B Tophi causing skin breakdown, nerve/tendon compression, or joint destruction refractory to medical therapy ✓
- C Elevated serum uric acid >9 mg/dL in the absence of tophi
- D All patients with tophaceous gout should have surgical debridement
Explanation
Surgical intervention in gout is reserved for specific indications: tophi causing skin ulceration/secondary infection, nerve or tendon compression (e.g., carpal tunnel syndrome from dorsal wrist tophi), joint destruction refractory to medical urate-lowering therapy, or cosmetically unacceptable large tophi. The primary treatment of gout is medical (allopurinol, febuxostat for urate lowering; colchicine/NSAIDs/steroids for acute attacks). Surgery does not cure the underlying metabolic disorder and tophi can recur if urate is not controlled medically. Elevated uric acid alone is not an orthopedic surgical indication.
Reference: Maheshwari Essential Orthopaedics, 6th ed.
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Written and medically reviewed by the StethoPrep medical team.