SLR - May 2012 - Chanel Houston
Reference: Lin, C.-T., Chang, S.-C., Chen, T.-M., Dai, N.-T., Fu, J.-P., Deng, S.-C., Tzeng, Y.-S. and Chen, S.-G. (2011), Free-flap resurfacing of tissue defects in the foot due to large gouty tophi. Microsurgery, 31: 610–615.
Scientific Literature Review
Reviewed by: Chanel Houston, DPM
Residency Program: Yale New Haven/DVA Healthcare System
Podiatric Relevance:
Large chronic tophaceous gout of the foot can oftentimes cause necrotic infections resulting in complex soft-tissue defects. Reconstruction of these complex soft-tissue defects of the foot can be a challenging task for the podiatric surgeon. This article is relevant to podiatric surgery because it focuses on the outcomes of free-flap reconstructive surgery for treating metatarsal joint defects caused by large chronic gouty tophi.
Methods:
Ten male patients ranging in ages from 36-72 years old were originally selected for this retrospective study; however, due to extenuating circumstances, only six were reviewed. All six patients were diagnosed to have large chronic tophaceous masses (>5 cm) located in either one or more metatarsophalangeal joints or in the tarsometatarsal joints. The most common symptoms among all patients were ulcerative lesions with purulent discharge followed by pain and swelling localized in the area of the tophus mass. The six patients underwent hospital admission and were started on broad-spectrum antibiotics in addition to serum urate-lowering agents. Surgical curettage and debridement was initially performed on the necrotic soft tissue over the involved pedal area, followed by plastic reconstructive surgery involving either a free anterolateral thigh (ALT) flap or a free medial sural flap.
Results:
Five patients had free ALT flap coverage, while one patient had medial sural flap coverage. The average defect for flap reconstruction was about 92.2 cm2. In two patients, wound healing was facilitated by a negative pressure wound therapy device due to excessive gouty discharge and wound infection. Post-operatively, all patients were instructed to follow a controlled diet, exercise, and take antigout medications in efforts to prevent the recurrence of tophaceous masses, since the urate could not entirely be resected by surgery alone. All free flaps in all six patients were applied to the dorsal foot and maintained viability and function. Recurrences of tophaceous gout occurred in all six patients after the mean follow-up period of 31.7 months. Each recurrence was treated conservatively since a second surgery could not be performed in the same location of the flap.
Conclusions:
Chronic tophaceous gout in the feet can cause extensively severe infections and skin necrosis. Surgical debridement is necessary when the necrotic, infected wound is located over a large tophaceous mass. Since gout mainly targets the forefoot or midfoot, extensive debridement in these regions presents a reconstruction dilemma due to the scarcity of muscle and skin in these areas. In this study, initial wound debridement was performed on all tophaceous masses, followed by microsurgical free-flap reconstruction for coverage of large ulcerations secondary to chronic tophaceous gout. Although all patients studied experienced gout recurrence, they each achieved good functional and cosmetic results with free-flap resurfacing of soft tissue defects caused by gouty tophi.