Abstract
Background: Chronic tophaceous gout develops after prolonged uncontrolled hyperuricaemia and can cause erosive joint damage, progressive deformity, skin thinning, pain and impaired mobility. Surgery may be considered when large tophi cause skin and footwear intolerance or substantial functional disability.
Case description and management: A 45-year-old obese man who worked as a farmer (body mass index, 31.1 kg/m²) presented with a 13-year history of painful bilateral forefoot swelling and progressive deformity, resulting in severe limitations in walking and footwear use. Examination showed bilateral first metatarsophalangeal deformity with lateral deviation of the great toes, large firm periarticular masses, thinned shiny skin, tenderness and markedly restricted motion. Serum urate was 15 mg/dL (laboratory reference range: 3.5–7.2 mg/dL for males) and serum creatinine was 1.6 mg/dL (laboratory reference range: 0.6–1.2 mg/dL for males). Radiographs demonstrated bilateral periarticular tophi with punched-out erosions and overhanging edges. He underwent single-stage bilateral surgical debulking without arthrodesis or reconstruction. Subsequent histopathological examination confirmed gout and excluded malignancy. Mild postoperative wound discharge resolved with local wound care and staged suture removal. At short-term follow-up, both wounds had healed and pain and footwear tolerance had improved modestly; however, residual tenderness, restricted joint motion, tophaceous prominence and hyperuricaemia persisted.
Conclusion: Surgical debulking may relieve local symptoms and reduce skin tension in advanced bilateral forefoot tophaceous gout, but sustained specialist-directed urate-lowering therapy and postoperative surveillance remain essential.