Acute gout after carpal tunnel release A carpal tunnel release was performed on three patients with known gout of the lower extremity but not of the upper extremity. Each patient had a postoperative inflammatory reaction in a treated hand, and there was some suspicion of an infection in two patients. However, the inflammatory reaction resolved only when treated with a combination of anti-inflammatory and antigout medication. (J HAND SURG 1992;17A:I031-2.)

Steven N. Graff, MD, John G. Seiler III, MD, and Jesse B. Jupiter, MD, Boston, Mass.

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carpal tunnel release was performed on three patients, each of whom was known to have gout, each of whom had either an apparent wound infection or a local inflammatory process postoperatively, and each of whom had resolution of symptoms only after treatment with anti-inflammatory and antigout medication. Surgical interventions of any kind have long been thought capable of precipitating gouty attacks. 1·6 The unusual feature of these three cases is the presentation of the inflammatory symptoms in or near the wound despite lack of tophaceous material in any of the carpal tunnels.

CASE REPORTS Case 1. A 57-year-old man sought treatment because of a 4-month history of typical bilateral carpal tunnel symptoms. Physical examination and electrodiagnostic studies confirmed the diagnosis. The patient had a history of renal failure that had required a renal transplant 7 years previously. He also had lower-extremity gout, which was treated with colchicine. Because the carpal tunnel symptoms did not abate after 2 months of conservative treatment, a bilateral carpal tunnel release was performed. At surgery neither exuberant flexor tenosynovitis nor tophaceous deposits were seen within the canal. The postoperative course was smooth until the sixth day, when the patient experienced pain and swelling of the right-hand wound, which opened superficially. He was afe-

From Massachusetts General Hospital, HarvardMedical School, BasIon, Mass. Received for publication May 15, 1991; accepted in revised form o«. 30, 1991. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Jesse B. Jupiter, MD, 5 WhittierPlace, Suite 102, Boston MA 02114. 3/1/35021

brile, and the wound appeared clean. After treatment with first one antibiotic and then another, the wound healed but the hand pain persisted. On postoperative day 21 there was another inflammatory episode, this time with painful finger motion and widespread swelling of the hand up to the fifth metacarpophalangeal joint. Blood cultures were taken, and the joint was aspirated. Each was sterile, but the serum uric acid level was 13 mg/dl (normal, 3 to 7 mg/dl), and urate crystals were seen in the joint aspirate. The diagnosis of gout was made, indomethacin was added to the regular colchicine regimen, and the symptoms resolved promptly. Case 2. A 58-year-old man had signs and symptoms of bilateral carpal tunnel syndrome and had known gout in his knees. The latter was treated with allopurinol, but the patient was not very compliant. He was treated conservatively for a time, but when the carpal tunnel symptoms worsened and appropriate testing confirmed the diagnosis, surgery was performed on the more severely involved left side. A moderate amount of tenosynovitis was found, but no tophaceous deposits were seen. Three days after surgery pain, swelling, and erythema developed, but the patient was afebrile and his condition was not toxic. He was treated expectantly, and no frank sepsis occurred. His symptoms did not defervesce, however, so he was treated with indomethacin and allopurinol. There was dramatic improvement in I day, and the problem was resolved in 3 days. Case 3. A 63-year-old man had bilateral carpal tunnel symptoms, confirmed by physical examination and electrodiagnostic studies. Although not on antigout medication, he had had an episode of podagra after prostate surgery 3 years previously. The right carpal tunnel was released, and neither gouty tophi nor significant flexor tenosynovitis were seen. On the second postoperative day he complained of discomfort centered over metacarpophalangeal joints 2, 3 and 4, but there were no systemic symptoms. He did not respond adequately to oral indomethacin and had to be admitted to the hospital for intravenous administration of colchicine, which relieved his symptoms. His serum uric acid level, white blood cell count, and erythrocyte sedimentation rate were all normal.

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Discussion Gout is uncommon in the upper extremity, and when it does occur it is typically associated with an advanced stage of the disease. Straub et al. 7 noted this in 21 patients with tophaceous gout of the upper extremity. These authors found the elbow and proximal interphalangeal joints to be most commonly involved, followed in order by the metacarpophalangeal and distal interphalangeal joints. Gouty deposits may manifest themselves with arthritis, dermatitis, skin ulceration, draining sinuses, tenosynovitis, tendon rupture, or nerve entrapment. 8 The latter is rare and has been associated with tophaceous tenosynovitis in the carpal canal.":" In reviewing 644 cases of carpal tunnel, Phalen" found only two that were due to this phenomenon. Postoperative gout has been observed after a variety of other surgical procedures (including the postanal fistulectomy of Louis XIV of France);': 3-6S naith and Scotf studied 10 patients, only one of whom had a diagnosis of gout, who underwent major abdominal or vascular procedures. Preoperative and postoperative levels of plasma uric acid, urinary uric acid, uric acid clearance, and urinary uric acid/ creatinine ratio were measured. A two- to threefold increase was found in urinary uric acid as well as uric acid clearance in all 10 patients within 48 hours after surgery. The other studies showed no consistent change. It was postulated that these changes might be due to a specific renal mechanism that increases urate clearance, but the mechanism for this is not known. It could be due to anesthesia- 8 or postoperative increases in ACTH or cortisol levels, !4 because the latter are known to have a uricosuric effect. IS Other possible mechanisms include a postoperative alteration in the relationship between urate crystals and biomembranes (Weissman G, Rita GA, Zurler RB. Molecular basis of gouty inflammation. Abstracts of the VII European Rheumatology Congress, Brighton, September, 1971), perioperative dehydration promoting formation of sodium urate crystals, I surgical injury to cells causing an increase in formation of urate crystals," and a penicillin reaction. 8 None of Snaith and Scott's patients had postoperative gouty attacks. Straub et al.? and Moore and Weiland 8 note that surgeons operating on patients with gout should be aware of the possibility of an acute gout attack after surgery, and they recommend the use of colchicine in the perioperative period. Although acute gouty attacks may occur despite this prophylaxis (they did in about one third of the patients reported by Straub et al.), its use

The Journal of HAND SURGERY

is still recommended. Whenever pain, swelling, erythema, and warmth develop in and around a surgical wound, infection is always the first thing to consider, but if the symptoms fail to respond to antibiotics and if the patient has a history of gout, the use of antigout and antiinflammatory medications are certainly indicated. A resolution of the signs and symptoms will confirm the diagnosis and obviate the need for further invasive diagnostic studies.

REFERENCES 1. Rodnan GP. Invitation to the gout-a consideration of the role of various predisposing factors in the genesis of acute gouty arthritis. Trans Stud Coli Physicians Phila 1967;35:47-62. 2. Snaith ML, Scott JT. Uric acid excretion and surgery. Ann Rheum Dis 1972;31:162-5. 3. Berger HJ, Ballen PH. Gouty arthritis as a complication of ophthalmic surgery. Am J Ophthalmol 1966;62:755. 4. DiNovis JP. Gout, phlebitis, and carcinoma in a postsurgical podiatry patient. J Am Podiatr Med Assoc 1988;78:328. 5. Scott HW, Dean RH, Shull HJ, Gluck FW. Metabolic complicationsof jejunoileal bypass operationsfor morbid obesity. Ann Rev Med 1976;27:397-405. 6. KellettHA, MacLarenIF, Toft AD. Gout and pseudogout precipitated by parathyroidectomy. Scott Med J 1982;27:250-1. 7. Straub LR, Smith JW, Carpenter GK Jr, Dietz GH. The surgery of gout in the upper extremity. J Bone Joint Surg 1961;43A:731-52. 8. Moore JR, Weiland AJ. Gouty tenosynovitis in the hand. J HAND SURG 1985;IOA:291-5. 9. Champion D. Gouty tenosynovitis and the carpal tunnel syndrome. Med J Aust 1969;1:1030-2. 10. Pledger SR, Hirsch B, Freiberg RA. Bilateral carpal tunnel syndrome secondary to gouty tenosynovitis: a case report. Clin Orthop 1976;118:188-9. 11. AbrahamssonSO. Gouty tenosynovitis simulating an infection: a case report. Acta Orthop Scand 1987;58: 282-3. 12. Primm DD, Allen JR. Gouty involvement of a flexor tendon in the hand. J HAND SURG 1983;8:863-5. 13. Phalen GS. The carpal tunnel syndrome: 17 years experience in diagnosis and treatment in 644 hands. J Bone Joint Surg 1966;48A:21 1-28. 14. Sandberg AA, Eik-Nes K, Samuels LT, Tyler FH. The effects of surgery on the blood levels and metabolism of 17-hydroxycorticosteroids in man. J Clin Invest 1954;33: 1509. 15. Gutman AB, Yu TF. Effects of adrenocorticotropic hormone (ACTH) in gout. Am J Med 1950;9:24.

Acute gout after carpal tunnel release.

A carpal tunnel release was performed on three patients with known gout of the lower extremity but not of the upper extremity. Each patient had a post...
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