The last defence? Surgical aspects of gouty arthritis of hand and wrist.

OBJECTIVE: To review the epidemiology, pathophysiology, clinical manifestations, diagnosis, and treatment of gouty arthritis of the hand and wrist, with a focus on the surgical aspects. DATA SOURCES AND EXTRACTION: Electronic databases including MEDLINE, PubMed, and the Cochrane library were searched with the key words of "gouty arthritis", "hand", "wrist", and "surgical". STUDY SELECTION: A total of 55 articles were selected for inclusion in this review. DATA SYNTHESIS: There is no existing study for the overall prevalence of gout in Asia, though one study showed that it was 3.1% in Taiwan. Its pathophysiology entails hyperuricaemia, trauma, lower temperatures, and previous diseases. Gouty arthritis of hand and wrist presents as acute wrist pain, subcutaneous or peritendinous tophi, tenosynovitis, entrapment neuropathy, tendon rupture, or even bone destruction. Demonstration of negatively birefringent crystals in the absence of organisms and a normal white cell count in synovial fluid confirm the diagnosis. Medical treatment including non-steroidal anti-inflammatory drugs, colchicines, allopurinol, uricosuric agents, and lifestyle modifications remain the mainstay of treatment. Surgical treatment options for tophaceous gout involve decompression by aspiration, incision and drainage, tenosynovectomy, shaving procedures, and complex surgical approach. CONCLUSION. While medical treatment remains the mainstay of treatment for gouty arthritis of the hand and wrist, 5% of patients may not respond. In this group, surgery is often performed in advanced stages, but yields less-than-satisfactory outcomes. Gouty arthritis is difficult to treat when it starts to cause stiffness and deformities. Although more studies are needed to evaluate the outcomes, the authors suggest that one possible solution is pre-emptive surgery.