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 tend to erode and destroy bone and joint cartilage, synovial membrane, tendons and ligaments, causing hand and foot deformities, joint dysfunction and difficult to handle.
1. Gout stones in the metacarpophalangeal joint
Gout stones are mainly distributed along the joint capsule and extensor tendons, so a lateral curved incision should be made in the metacarpophalangeal joint, and the skin and subcutaneous tissue should be cut open. 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 to make the skin of the back of the hand fit closely with the depressed trauma of the back of the hand, which helps to stop bleeding and tension-free healing of the trauma.
2.Gout stones at the interphalangeal joints
The gouty stones can be seen in the extensor tendons, joints, lateral collateral ligaments and palmar plate, and when the gouty stones are large, they can compress the nerves of the intrinsic finger arteries bilaterally. The gouty stones are scraped thoroughly and repeatedly flushed with large amounts of saline. If the central tendon is defective after excision of gout stones in the proximal interphalangeal joint, the long palmar tendon can be transplanted for repair. 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.Metacarpal gout stones
Most of them are deposited under the skin and are more superficial, so a lateral or oblique incision should be made and the incision should be sutured after scraping with a spatula.
4.Postoperative treatment
Take colchicine 3 times a day at 0.5mg for 1 week after surgery, and then change to 0.5mg twice a day for another week. Continue internal medicine to lower uric acid treatment.
5. 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 the irregularity of uric acid-lowering drugs and frequent alcohol consumption after surgery.
6. Clinical background
In China, gout patients were rare before the 1970s, but the number increased year by year in the 1980s, and rose linearly in the 1990s. In recent years, along with the improvement of quality of life and living standards, the number of people suffering from gout has increased sharply. In recent years, the number of people suffering from gout has risen sharply along with the improvement in quality of life and living standards. Moreover, as the Chinese population ages, the number of patients with gout stones is increasing. Gout stones are characteristic lesions of gout, in which small pinpoint crystals of uric acid are deposited in joint cartilage and bursae, forming a yellowish-white flabby mass, usually the size of a sesame seed to a pigeon’s egg, and occasionally as large as an egg, mostly in the hands and feet. Gout stones tend to erode and destroy bone and joint cartilage, synovial membrane, tendons and ligaments, and cause joint swelling, pain and restricted movement, resulting in joint ankylosis, which seriously affects the function of joints and even causes finger disability. Internal treatment can only control the attack of gout and the development of gout stones, but cannot eliminate the formed gout stones in the hand. Surgery is an effective means of treating gout stones in the hand. Surgical removal of gout stones can not only correct the deformity, preserve and improve the function of the joints in 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.
7. 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 stones compressing nerves and causing nerve compression symptoms.
(4) Difficulty in diagnosis requires tissue biopsy.
(5) Affects aesthetics.
(6) To reduce the total amount of uric acid and control gout attacks.
8. Timing of gout stone surgery
Surgery is usually performed in the chronic phase, after the blood sedimentation has been controlled to normal or close to normal. In the chronic stage, 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 stage, 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 attack period, the joint is braked, colchicine and non-steroidal drugs are applied, and surgery is considered after the local redness 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 to do with the timing of surgery, because those with elevated uric acid levels may not have an acute attack of gout, and conversely, those with an acute attack of gout may have normal uric acid levels. In contrast, blood sedimentation is an important indicator of the active phase of gout.
9. Distribution characteristics of gout stones in the hand and surgical points
Gout stones in the hand are mainly distributed along the extensor tendons, metacarpophalangeal joints, interphalangeal joint capsule, and lateral collateral ligaments, and mainly subcutaneously on the palmar side, and rarely along the flexor tendon sheath. They were not seen in this group of cases. Key points of surgical treatment.
(1) If the gouty stone is large and it is difficult to remove the whole piece, it can be removed in pieces.
(2) Preserve the lateral collateral ligament, tendon and tendon cap tissue as much as possible to reduce postoperative joint instability and to facilitate postoperative functional recovery.
(3) For patients with tendon defects, the long palmar tendon can be transplanted for repair, with attention to tendon tension adjustment.
(4) For patients with severe joint destruction, joint fusion should be performed instead of arthroplasty.
(5) For patients with large gout stones in the fingers, free the intrinsic finger artery nerves bilaterally before removing the gout 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.
10.Auxiliary medical treatment after surgery
Surgery is one of the factors triggering acute attacks of gouty arthritis, and hyperthermia is commonly used after gouty stones, mostly appearing 3-7 days after surgery, so colchicine is given after surgery, 3 times a day, 0.5mg each time; after a week, it is changed to 2 times a day, 0.5mg each time, and the drug is stopped after a week of treatment.