Figure 2 Once through the nail plate, the haematoma willevacuate through the defect created.

Correspondence and communications 1933

training. As the instrument is cheap,1 this allows it be usedas a ‘once-only’ without additional costs for sterilisation.

Conflict of interest/Funding

None

References

1. STIEFEL� BIOPSY PUNCH. 2 mm diameter, http://www.biopsypunch.com/biopsypunch.htm. Cost w £21.50 for pack of10 (22.10.2009).

2. Palamarchuk HJ. An improved approach to evacuation of sub-ungual hematoma. J Am Pod Med Assoc. 1989;79:566e9.

3. Ciocon D, Gowrishankar TR, Herndon T, et al. How low shouldyou go: novel device for nail trephination. Dermatol Surg 2006Jun;32:828e33.

4. Helms A, Brodell RT. Surgical pearl: prompt treatment of sub-ungual hematoma by decompression. J Am Acad Dermatol 2000Mar;42:508e9.

Nakul KainOmmen Koshy

Whiston Hospital, Warrington Road, Prescot Merseyside,Liverpool L355DR, United Kingdom

E-mail address: nakulkain@hotmail.com

ª 2010 British Association of Plastic, Reconstructive and AestheticSurgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjps.2010.03.023

Surgical treatment ofsubcutaneous tophaceous gout

Dear Editor,

Asymptomatic tophaceous gout can be treated by serumurate lowering agents, but if cosmetic deformity,

functional impairment or draining sinus exists, surgicalintervention is inevitable.1 However, surgery for topha-ceous gout is associated with a relatively high rate ofcomplications, and improper debridement of the topha-ceous lesions may result in delayed wound healing oroverlying skin necrosis.2 Therefore, tophaceous gout is anirritating and challenging disease for a plastic surgeon.

Comparing with surgical debridement, Versajet�

(Smith and Nephew, Largo, Florida, USA) hydrosurgerysystem can remove target tissue selectively and minimiseunnecessary injury to normal tissue. Also, through its highpressure pulsatile lavage effect, it can be anticipated toreduce the bacterial load of the wound and prevent thediffusion of microbial contamination deeper into thewound.3

We present two cases of subcutaneous tophaceous goutdeveloped on lateral malleolar area and the successful useof the Versajet� for wound preparation for skin graft andlocal flap coverage.

Case 1

48-year-old male presented with skin defect on left lateralmalleolar area (Figure 1A). He had been diagnosed of gout15 years ago.

On physical examination, there was about 6� 5 cm sizedskin defect on left lateral malleolar area and multiple hardgouty tophi were exposed through the wound. Pseudo-monas aeruginosa was grown on wound culture.

To prevent the acute attack of gouty arthritis whichcould be induced by operation, colchicine, allopurinol, andmethylprednisolone were administered pre-operatively.

Serial debridement with Versajet� was performed withminimising injury to normal tissue. To facilitate the removalof tophi, we used warm (37 �C) normal saline solution.Histologic evaluation for the lesion revealed chronic gran-ulomatous inflammation including palisading histiocytesand foreign body type giant cells around the crystal likedeposition and it was consistent with gouty tophi(Figure 1B).

After debridement, VAC (vacuum-assisted closure)dressing was applied to help formation of granulation tissuefor 10 days, and split thickness skin graft was performed forthe coverage of the defect. Complications such as recur-rence or infection did not occur on 3 months of follow-up(Figure 1C).

Case 2

54-year-old male presented with subcutaneous nodule onleft lateral malleolar and heel area (Figure 2A). His pastmedical history included 10-years history of gouty arthritis.On physical examination, there were about 5� 5 cm and2� 3 cm sized nodules on left lateral malleolar area andheel area respectively.

The surgery started with excision of thinned, nonviableskin. Then, with the aid of Versajet�, serial debridement ofgouty tophi was performed. Since we could preserve suffi-cient amount of normal tissue, the defect area could becovered with local skin flap. No complications occurred on 3months of follow-up (Figure 2B).

Figure 1 (A) Pre-operative photo; (B) Photomicrograph (Haematoxylin-eosin, X100); (C) Post-operative photo.

Figure 2 (A) Pre-operative photo; (B) Post-operative photo.

1934 Correspondence and communications

Discussion

The treatment of subcutaneous gouty tophi depends ontheir size. In small tophi with no associated symptoms,maintaining low blood uric acid level with medical agentscan decreases the size of tophi. However, if there are mass-related symptoms or skin necrosis developed by localischaemia or secondary wound infection, surgical treat-ment is indicated.2,4

But, in many cases the traditional curettage ordebridement cannot remove the crystals around the noduleand fibrotic tissue sufficiently, and there have been manypost-operative complications such as delayed wound heal-ing or skin necrosis.1

To overcome the limitation of surgical treatment, Leeet al.2 applied soft tissue shaving system, which was morecommonly used in the fields of arthroscopic and endoscopicsinus surgery, to the removal of subcutaneous gouty tophi.And they could reduce complication rate and obtainimproved results for the treatment of gouty tophi.

Versajet� (Smith and Nephew, Largo, Florida, USA)hydrosurgery system enables surgeon to debride the targettissue precisely with high pressurised saline stream.

Comparing with traditional cold-knife debridement orcurettage, it can create a smoother, less irregular woundsurface, ready to receive skin graft. Also, because thetarget tissue is cut and removed simultaneously (Venturieffect), it can be used in an infected wound safely withoutthe risk of contaminating the environment.3

In applying Versajet� to the treatment of gouty tophi, itis more effective to use 37 �C warm normal saline as irri-gation solution, because the solubility of urate is markedlytemperature dependent with two fold increase in solubilitybetween 25w37 �C.5

To prevent the recurrence of gouty tophi post-operatively, medical therapy is imperative. Because uricacid level of less than 6.0 mg/dl is needed for preventionof acute gouty arthritis, and uric acid level of less than5.0 mg/dl is required for resorption of existing tophi,the post-operative serum uric acid level should be below5.0w6.0 mg/dl to prevent the recurrence and to removethe remnant tophi.2

After all, we concluded that Versajet� is very effectivetool for the removal of subcutaneous gouty tophi, and itcould be a good alternative modality for the surgicaltreatment of subcutaneous gouty tophi.

Correspondence and communications 1935

Conflict of interest

The authors have no financial interests in this research orin any of the techniques or equipments used in thisstudy. The authors have no conflicts of interest todisclose.

Funding

None.

References

1. Casagrande PA. Surgery of tophaceous gout. Semin ArthritisRheum 1971;1:262e73.

2. Lee SS, Lin SD, Lai CS, et al. The soft-tissue shaving procedurefor deformity management of chronic tophaceous gout. AnnPlast Surg 2003;51:372e5.

3. Vanwijck R, Kaba L, Boland S, et al. Immediate skin grafting ofsub-acute and chronic wounds debrided by hydrosurgery. J PlastReconstr Aesthet Surg 2010;63:544e9.

4. Ou KL, Tzeng YS, Yu CC, et al. Resurfacing tophaceous gout inthe foot with anterolateral thigh flap. Microsurgery; 2009;. doi:10.1002/micr.20693.

5. Kelly WN, Wortmann RL. Gout and hyperuricemia. In: Kelly WN,RuddyS,Harris ED, et al., editors.TextbookofRheumatology. 5thed., vol. 2. Philadelphia: W.B. Saunders Co; 1997. p. 1313e51.

Jung Ho LeeJeong Yong Park

Je Won SeoDeuk Young OhSang Tae Ahn

Jong-Won RhieDepartment of Plastic Surgery,

Seoul St. Mary’s Hospital, College of Medicine,The Catholic University of Korea,

505 Banpo-dong, Seocho-gu,Seoul, 137-701, Republic of Korea

E-mail address: rhie@catholic.ac.kr

ª 2010 British Association of Plastic, Reconstructive and AestheticSurgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjps.2010.03.019