Abstract

The olecranon bursa is very commonly involved in tophaceous gout because of the tendency of monosodium urate crystals to deposit in superficial structures with low temperatures. Surgery is indicated if the olecranon tophus is recalcitrant to medical treatment. Open surgery requires a long incision over the tophus and may lead to wound complications. Endoscopic debridement of the tophus can reduce the risk of wound complications. In this Technical Note, the technical details of endoscopic decompression of an olecranon tophus are described. This endoscopic technique also allows debridement of tophus infiltration of the triceps tendon.

Gout is an inflammatory metabolic disorder that occurs in conjunction with hyperuricemia and is a result of the deposition of monosodium urate monohydrate crystals within the periarticular soft tissues.1Endoscopic decompression of a gouty tophus at the hand dorsum.,2de Ávila Fernandes E. Sandim G.B. Mitraud S.A.V. Kubota E.S. Ferrari A.J.L. Fernandes A.R.C. Sonographic description and classification of tendinous involvement in relation to tophi in chronic tophaceous gout. Gout may cause bursitis, and the olecranon bursa is one of the most affected bursas. The olecranon bursa is very commonly involved in tophaceous gout because of the tendency of monosodium urate crystals to deposit in superficial structures with low temperatures.3Özdemir G. Deveci A. Andıç K. Yaşar N.E. Bilateral olecranon tophaceous gout bursitis. Medical treatment including lifestyle and dietary modifications and drug therapy remains the mainstay of treatment. Without proper and timely treatment, tophi develop approximately 10 years after the onset of the disease.1Endoscopic decompression of a gouty tophus at the hand dorsum. The process of tophaceous deposition advances progressively and leads to numerous problems. The overlying skin of the tophus can ulcerate, and secondary infection will occur. The large tophus can cause local ischemia to the surrounding skin and affect ulcer healing. Moreover, this can lead to wound complications after open resection of the tophus.4Endoscopic resection of the gouty tophi of the first metatarsophalangeal joint.Tophaceous material may present in a liquid, pasty, or chalky and/or granular state.1Endoscopic decompression of a gouty tophus at the hand dorsum. Treatment may be as simple as aspirating the liquid or squeezing out pasty tophaceous material. However, open debridement is needed for tophi in the chalky and/or granular state. Open surgery for tophaceous gout requires a long incision directly over the tophus and is associated with a relatively high rate of wound complications, for example, symptomatic scar adhesion of the underlying structures and overlying skin necrosis.1Endoscopic decompression of a gouty tophus at the hand dorsum. Techniques of endoscopic debridement of the tophus have been described.1Endoscopic decompression of a gouty tophus at the hand dorsum.,4Endoscopic resection of the gouty tophi of the first metatarsophalangeal joint.,5Endoscopic resection of gouty tophus of the patellar tendon. These minimally invasive techniques allow resection of the gouty tophus through small incisions away from the lesion and minimize the risk of wound dehiscence and persistent tophaceous discharge.5Endoscopic resection of gouty tophus of the patellar tendon.The purpose of this Technical Note is to describe the details of endoscopic decompression of an olecranon tophus. This technique is indicated for a symptomatic olecranon tophus, impending rupture of the tophus, repeated ulceration, or persistent tophaceous discharge that is recalcitrant to medical treatment. It is also indicated for lowering of the total body urate level (metabolic reasons) or cosmetic restoration. Tophaceous invasion of the underlying triceps tendon is another indication for surgery. The endoscopic procedure is contraindicated in patients in whom neoplasm is suggested. The red-flag signs suggestive of neoplastic pathology include a rapidly expanding growth, failure of initial treatment, weight loss, and history of neoplasia (Table 1).6Blackwell J.R. Bruce A. Hay B.A. Alexander M. Bolt A.M. Hay S.M. Olecranon bursitis: A systematic overview.

Table 1Indications and Contraindications of Endoscopic Decompression of Olecranon Tophus

Technique Preoperative Planning and Patient PositioningPreoperative radiographs of the involved elbow can show the soft-tissue swelling at the olecranon, which may be calcified (Fig 1). Preoperative magnetic resonance imaging is useful for confirmation of the diagnosis and exclusion of other pathology. It is also useful for study of the relation between the tophus and the surrounding structures. It is especially important if clinically, the mass is overlying the triceps tendon. Magnetic resonance imaging can be used to evaluate the condition of the triceps tendon and detect any invasion of the tophus into the tendon (Fig 2).

Fig 1Endoscopic decompression of olecranon tophus in right elbow with patient in prone position. A preoperative radiograph of the elbow shows the soft-tissue swelling at the olecranon, which is calcified. (T, calcified tophus.)

Fig 2Endoscopic decompression of olecranon tophus in right elbow with patient in prone position. Preoperative magnetic resonance imaging of the elbow shows tophus infiltration of the triceps tendon. (A) Transverse image at level of olecranon (Ol) bone. (B) Transverse image at level of triceps tendon (Tr). (T, tophus.)

The patient is placed in the prone position with an arm support to keep the shoulder in 90° of abduction and the elbow in 90° of flexion. An ipsilateral arm tourniquet is used to provide a bloodless surgical field. Fluid inflow is driven by gravity, and an arthro-pump is not used. A 4.0-mm, 30° arthroscope (Dyonics; Smith & Nephew, Andover, MA) is used for this procedure.

 Portal Placement and Creation of Initial Endoscopic Working SpaceThe procedure is performed via the proximal portal and distal radial portal. The proximal portal is at the junction between the proximal edge of the tophus and the midline of the posterior elbow. The distal radial portal is at the distal radial corner of the tophus (Fig 3). We avoid placement of the distal portal over the ulnar side of the tophus to reduce the risk of injury to the ulnar nerve and to prevent an ulnar scar, which may be painful when the patient rests the elbow on a table. Placement of the distal portal over the midline should also be avoided because a painful scar may be formed over the proximal ulnar bone.

Fig 3Endoscopic decompression of olecranon tophus in right elbow with patient in prone position. The portals used for the endoscopic procedure are shown: distal radial portal (DRP) and proximal portal (PP). (T, tophus; Tr, triceps tendon; UN, ulnar nerve.)

Five-millimeter skin incisions are made at the portal sites. The subcutaneous tissue is bluntly dissected down to the tophus with a hemostat. A trocar-cannula (Dyonics; Smith & Nephew) is introduced via both portals and is passed through the tophus as superficially as possible. This tract between the 2 portals forms the initial endoscopic working space (Fig 4).

Fig 4Endoscopic decompression of olecranon tophus in right elbow with patient in prone position. (A) A trocar-cannula is introduced via both the proximal portal (PP) and distal radial portal (DRP) and passes through the tophus as superficially as possible. This tract between the 2 portals forms the initial endoscopic working space. (B) Endoscopy of the tophus is performed via the 2 portals. The PP is the viewing portal, and the DRP is the working portal.

 Debridement of Deep Part of TophusThe proximal and distal radial portals are interchangeable as the viewing and working portals. The part deep to the initial endoscopic working space is usually adhered to the underlying bone and triceps tendon and is relatively immobile. This facilitates debridement with an arthroscopic shaver (Dyonics; Smith & Nephew) and arthroscopic punch forceps (Acufex; Smith & Nephew) (Fig 5). Debridement of the medial edge of the tophus should be performed under direct endoscopic visualization, and the instrument should not go far beyond the boundary of the tophus to avoid injury to the ulnar nerve.

Fig 5Endoscopic decompression of olecranon tophus in right elbow with patient in prone position. The proximal portal is the viewing portal, and the distal radial portal is the working portal. (A, B) The deep part of the tophus (T) is debrided with an arthroscopic shaver (AS) and an arthroscopic punch forceps (P).

 Debridement of Superficial Part of TophusThe proximal and distal radial portals are interchangeable as the viewing and working portals. The superficial part of the tophus is usually adhered to the overlying skin and is mobile. The tophus can be held by the assistant and pushed toward the instrument to facilitate debridement by the arthroscopic shaver and arthroscopic punch forceps (Fig 6).

Fig 6Endoscopic decompression of olecranon tophus in right elbow with patient in prone position. The proximal portal (PP) is the viewing portal, and the distal radial portal (DRP) is the working portal. (A) The assistant holds the superficial part of the tophus and pushes it toward the instrument to facilitate debridement. (B) An endoscopic view shows debridement of the superficial part of the tophus (T) by the arthroscopic shaver (AS).

 Debridement of Triceps TendonThe distal radial portal is the viewing portal, and the proximal portal is the working portal. The tophaceous material superficial to the triceps tendon is removed with the arthroscopic shaver and arthroscopic punch forceps. Thereafter, the triceps tendon is exposed. The tendon can be cut longitudinally with a No. 15 surgical scalpel blade to expose the intratendinous tophaceous deposits, which undergo debulking with the arthroscopic shaver and arthroscopic punch forceps (Fig 7, Video 1, Table 2). After the operation, the wounds are closed with simple sutures, and elbow mobilization is started on the second postoperative day.

Fig 7Endoscopic decompression of olecranon tophus in right elbow with patient in prone position. The distal radial portal is the viewing portal, and the proximal portal is the working portal. The triceps tendon (Tr) can be cut longitudinally with a No. 15 surgical scalpel blade to expose the intratendinous tophaceous deposits. (K, knife.)

Table 2Pearls and Pitfalls of Endoscopic Decompression of Olecranon Tophus

DiscussionTophaceous deposition of tendons has been reported, including the flexor and extensor tendons of the hand, distal biceps tendon, Achilles tendon, quadriceps tendon, patellar tendon, tibialis anterior tendon, and peroneal tendons.1Endoscopic decompression of a gouty tophus at the hand dorsum.,5Endoscopic resection of gouty tophus of the patellar tendon.,7Fairhurst R.J. Schwartz A.M. Rozmaryn L.M. Gouty tenosynovitis of the distal biceps tendon insertion complicated by partial rupture. First case and review of the literature. Tophi generally envelop the tendon or there is no relation between them.2de Ávila Fernandes E. Sandim G.B. Mitraud S.A.V. Kubota E.S. Ferrari A.J.L. Fernandes A.R.C. Sonographic description and classification of tendinous involvement in relation to tophi in chronic tophaceous gout. Rarely, tophi can also be found at the insertion site of the tendon, can cause extrinsic compression, or can be located inside the tendon.2de Ávila Fernandes E. Sandim G.B. Mitraud S.A.V. Kubota E.S. Ferrari A.J.L. Fernandes A.R.C. Sonographic description and classification of tendinous involvement in relation to tophi in chronic tophaceous gout. In the case illustrated in this article, the olecranon tophus infiltrated into the triceps tendon, which—to our knowledge—has not been reported in the English-language literature. This tophus infiltration into the tendon may cause local anatomic deformities with consequent limitation or loss of articular movements.2de Ávila Fernandes E. Sandim G.B. Mitraud S.A.V. Kubota E.S. Ferrari A.J.L. Fernandes A.R.C. Sonographic description and classification of tendinous involvement in relation to tophi in chronic tophaceous gout. Previously, it was believed that gouty tophi did not lead to tendon destruction. However, there are many reports of tendon ruptures with tophaceous deposition intra-tendinously and para-tendinously, and it is now accepted that gouty tophi may play a role in tendon destruction.2de Ávila Fernandes E. Sandim G.B. Mitraud S.A.V. Kubota E.S. Ferrari A.J.L. Fernandes A.R.C. Sonographic description and classification of tendinous involvement in relation to tophi in chronic tophaceous gout. Monosodium urate crystals can directly interact with tenocytes to reduce cell viability and function, which may result in spontaneous ruptures of involved tendons.5Endoscopic resection of gouty tophus of the patellar tendon.,8Chhana A. Callon K.E. Dray M. et al.Interactions between tenocytes and monosodium urate monohydrate crystals: Implications for tendon involvement in gout. The inflammatory response to urate deposits is associated with connective tissue damage accompanied by collagen lysis and cystic changes. Inflammatory compromise of connective tissue integrity, loss of tendon tensile strength, and fibrinous exudation of active tophi may also lead to tendon tears and ruptures.7Fairhurst R.J. Schwartz A.M. Rozmaryn L.M. Gouty tenosynovitis of the distal biceps tendon insertion complicated by partial rupture. First case and review of the literature. For those case of tophus infiltration into the tendon, it is possible to indicate clinical treatment to reduce the dimensions of the tophi to avoid rupture of the tendon.2de Ávila Fernandes E. Sandim G.B. Mitraud S.A.V. Kubota E.S. Ferrari A.J.L. Fernandes A.R.C. Sonographic description and classification of tendinous involvement in relation to tophi in chronic tophaceous gout.The described minimally invasive technique has the advantages of less soft-tissue trauma, better cosmetic results, and fewer wound complications. The potential risks of this technique include ulnar nerve injury, compartment syndrome of the forearm due to excessive extravasation, triceps tendon injury, skin necrosis, wound dehiscence, and persistent tophaceous discharge (Table 3). This technique is not technically demanding and can be attempted by the average elbow arthroscopist.

Table 3Advantages and Risks of Endoscopic Decompression of Olecranon Tophus

Supplementary data

Video 1

Endoscopic decompression of olecranon tophus in right elbow. The patient is in the prone position. The proximal portal is the viewing portal, and the distal portal is the working portal. The deep part of the tophus is debrided with an arthroscopic shaver and arthroscopic punch forceps. The assistant holds the tophus and pushes it toward the shaver or punch forceps during debridement of the superficial part of the tophus. After debridement of the tophus, the arthroscope is switched to the distal radial portal. The triceps tendon is cut longitudinally with a knife via the proximal portal to expose the intratendinous tophaceous deposits. The tophaceous material undergoes debridement with an arthroscopic shaver and punch forceps.

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Ann Rheum Dis. 73: 1737-1741Article InfoPublication History

Published online: June 19, 2021

Accepted: March 9, 2021

Received: February 8, 2021

Publication stageIn Press Corrected ProofFootnotes

The authors report no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material.

Identification

DOI: https://doi.org/10.1016/j.eats.2021.03.017

Copyright

© 2021 by the Arthroscopy Association of North America. Published by Elsevier.

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