With the improvement of people’s living standards and the aging of the population, there are more and more patients with gout stones in the hands. Gout stones easily erode and destroy bone and joint cartilage, synovial membrane, tendons and ligaments, causing hand and foot deformities, joint dysfunction and difficult to handle.
Gout stones in the metacarpophalangeal joint: mainly along the joint capsule and extensor tendon distribution, to be taken to the metacarpophalangeal joint lateral curved incision, cut the skin and subcutaneous tissue, more visible gout stones erosion tendon cap and tendon, try to retain the tendon to remove gout stones, if the gout stones are large, can be longitudinally dissected along the tendon
If the extensor tendon is completely eroded, the extensor tendon can be repaired by transplanting the palmaris longus tendon after the gout stones are removed. After the superficial gout stones are removed, more gout stones can be seen around the metacarpophalangeal joint capsule and lateral collateral ligament, some of which may be liquid, and the cartilage of the joint surface is degenerated, and even bone destruction of the metacarpal head can be seen. The lateral collateral ligament should be preserved as much as possible, and the gouty stones, including some intraosseous gouty stones, should be completely scraped out, the joint cavity and wounds should be repeatedly rinsed with a large amount of saline, the tourniquet should be loosened, and after complete hemostasis, the residual joint capsule, tendon cap and tendon tissue should be repaired with 4/0 Priligy tendon wire, and if the joint is unstable, the functional position of 1.2 kerf pins can be fixed for 3 weeks. Complete destruction of the metacarpophalangeal joint is rare, and metacarpophalangeal fusion is generally not performed. The original elevated skin on the back of the hand is not easily excised, and the incision is disposed of with drainage tubes and negative pressure suction, so that the skin on the back of the hand fits closely with the depressed trauma on the back of the hand, which helps to stop bleeding and tension-free healing of the trauma.
2, gout stones at the interphalangeal joint: generally take a dorsal straight incision or S-shaped incision, cut the skin and subcutaneous tissue, visible gout stones erode the extensor tendons, joints and lateral collateral ligaments, palmar plate, gout stones can compress bilateral intrinsic finger artery nerves when larger, gout stones should be free and protected, larger gout stones can be dissected longitudinally and removed in pieces, try to retain the residual tendons, and remove the gout stones. The gout stones should be scraped thoroughly and repeatedly flushed with plenty of saline. If the central tendon is defective after excision of gout stones in the proximal interphalangeal joint, it can be repaired by transplanting the long palmar tendon. For patients with severe destruction of the interphalangeal joint, joint fusion can be performed. For some elderly patients with severe destruction of the osteoarthritic joints of the fingers, finger amputation is feasible.
3. Gout stones on the metacarpal side of the finger, mostly deposited under the skin, are more superficial, so a lateral or oblique incision should be made, and the incision should be scraped off with a scraping spoon and sutured.
I. Postoperative treatment Colchicine should be taken 3 times a day at 0.5mg for 1 week after surgery, and then twice a day at 0.5mg for another week. Continue internal medicine to lower uric acid treatment.
1. Results
In all cases, the surgical incisions healed in one stage without skin necrosis. The nodal deformity was corrected and the function of finger movement was improved compared with that before surgery. One case of recurrence of gout stone in the hand was due to irregular intake of uric acid-lowering drugs and frequent alcohol consumption after surgery.
Clinical background: Gout patients were rare in China before the 1970s, rising year by year in the 1980s and linearly in the 1990s, and the number of people suffering from gout has increased sharply in recent years along with the improvement of quality of life and living standards [1]. Moreover, as the aging of the Chinese population increases, the number of patients with gout stones is also increasing. Gout stones are characteristic lesions of gout, in which small pinpoint crystals of uric acid are deposited in joint cartilage and bursae, forming yellowish-white flabby masses, usually the size of sesame seeds to pigeon eggs, and occasionally as large as eggs, mostly in the hands and feet. Gout stones tend to erode and destroy bone and joint cartilage, synovial membrane, tendons, and ligaments, and this causes joint swelling, pain, and restricted movement [2], resulting in joint ankylosis, which seriously affects the function of the joint and even causes finger disability. Internal treatment can only control the attack of gout and the development of gout stones, but cannot eliminate the gout stones that have formed in the hand. Surgery is an effective means of treating gout stones in the hand [3]. Surgical removal of gout stones can not only correct the deformity, preserve and improve the function of the joints of the hand, but also reduce the total amount of uric acid in the body, reduce the number of gout attacks, and prevent further damage to the joints and soft tissues.
2. Indications for surgery.
① Gout stones break down and begin to discharge chalk-like material, and gout stones are removed to prevent secondary infection.
② Gout stones cause limb deformity and affect limb function.
③ Gout stone compressing the nerve and causing nerve compression symptoms.
④Difficulty in diagnosis requires tissue biopsy.
⑤ Affecting aesthetics.
⑥ Reduce the total amount of uric acid and control gout attacks [4].
3. Timing of gout stone surgery Surgery is usually chosen in the chronic phase, after the blood sedimentation has been controlled to be normal or close to normal. In the chronic phase of surgery, gout stones are mostly solid, which is convenient for surgical excision and less postoperative trauma oozing, which is conducive to incision healing; while in the acute phase, liquid gout stones are commonly used around the joints, which brings inconvenience to surgery, local skin redness and swelling, increasing the chance of infection, and more postoperative trauma oozing, which is not conducive to incision healing. During the acute phase, the joint is braked, colchicine and non-steroidal drugs are applied, and surgery is considered after the local redness, swelling and pain symptoms disappear. For patients with gouty stones with infection, they can be reopened in phase I. After the infection is controlled, the wound can be repaired after complete removal of gouty stones in phase II. The level of blood uric acid concentration has little relevance to the timing of surgery because those with elevated uric acid levels may not present with an acute attack of gout, and conversely, present with an acute attack of gout while uric acid levels can be normal [5]. In contrast, blood sedimentation is an important indicator of the active phase of gout.
4. Distribution characteristics and surgical points of gout stones in the hand: gout stones in the hand are mainly distributed along the extensor tendons, metacarpophalangeal and interphalangeal joint capsules, and lateral collateral ligaments, and on the palmar side, mainly under the skin, and rarely along the flexor tendon sheath. They were not seen in this group of cases. Key points of surgical treatment.
(1) If the gout stone is large and it is difficult to remove the whole piece, it can be removed in pieces.
②Try to preserve the lateral collateral ligaments, tendons and tendon cap tissues to reduce postoperative joint instability to facilitate postoperative functional recovery.
③For patients with tendon defects, the long palmar tendon can be transplanted for repair, with attention to tendon tension adjustment.
④For patients with severe joint destruction, joint fusion, rather than arthroplasty, should be performed.
⑤ For patients with large gouty stones in the fingers, free the intrinsic finger artery nerves bilaterally before removing the gouty stones to prevent accidental injury.
(6) Intraoperative hemostasis should be thorough, and the wound should be flushed with plenty of saline to reduce the residual gout stones.
(7) For the excess skin on the back of the hand and finger, it is not easy to excise too much, and the incision should be sutured loosely, and a drainage tube should be built into the incision to drain the skin under negative pressure, so that the skin at the incision can fit closely with the trauma, which is conducive to postoperative hemostasis and tension-free healing of the trauma, and also conducive to skin covering the local depressed trauma.
5, postoperative adjuvant medical treatment Surgery is one of the factors that induce acute attacks of gouty arthritis [6], gouty stones after surgery commonly hyperthermic reaction, mostly in 3-7 days after surgery, so postoperative colchicine was given, 3 times a day, 0.5 mg each time; after a week, it was changed to 2 times a day, 0.5 mg each time, and the drug was stopped after a week of treatment. Postoperative medical treatment was given.