Debridement of Gouty Tophus

Indications

  • Ulceration with chalky discharge and a non-healing wound
  • Secondary infection of the tophus or adjacent joint
  • Nerve compression, such as carpal tunnel or cubital tunnel syndrome
  • Mechanical block to joint motion, grip or footwear
  • Tendon impingement or threatened rupture, and symptomatic deformity

Position

  • Supine with a limb table and tourniquet, exsanguinating by elevation
  • Regional anaesthesia is an option for hand, wrist and foot tophi

Operative Steps

  1. Optimise urate lowering beforehand with rheumatology input, targeting serum urate below 0.36 mmol/L, or below 0.30 mmol/L with tophi
  2. Continue urate lowering therapy perioperatively
  3. Give flare prophylaxis with low dose colchicine, NSAID or prednisolone for the first months of urate lowering
  4. Incise directly over the tophus along skin tension lines, excising only thinned or ulcerated skin
  5. Expose the chalky white tophaceous deposit and identify the adjacent tendons and neurovascular bundles
  6. Curette the tophus piecemeal, protecting tendons and neurovascular bundles
  7. Decompress the nerve fully when compressed, as in carpal tunnel release
  8. Excise inflamed synovium and bone erosion deposits, and consider arthrodesis for a destroyed joint
  9. Send tissue for polarised microscopy, which shows needle shaped negatively birefringent urate crystals, and for culture
  10. Irrigate and preserve the skin envelope
  11. Close primarily if tension free. Otherwise leave open, apply negative pressure or plan delayed closure

Postoperative Care

  • Elevate and splint, then start early motion
  • Continue urate lowering and flare prophylaxis, and monitor serum urate
  • Antibiotics only for proven or suspected infection
  • Wound review for healing and infection

Complications

  • Poor wound healing from thin skin, residual urate and poor perfusion
  • Infection and sinus formation
  • Recurrence if serum urate stays above target
  • Tendon rupture or adhesions, and digital nerve injury
  • Postoperative acute gout flare

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 12 October 2026.