Endoscopic Decompression of a Gouty Tophus at the Hand Dorsum Tun Hing Lui, M.B.B.S.(HK), F.R.C.S.(Edin), F.H.K.A.M., F.H.K.C.O.S.  Arthroscopy Techniques  Volume 6, Issue 3, Pages e827-e832 (June 2017) DOI: 10.1016/j.eats.2017.02.011 Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 1 Endoscopic decompression of gouty tophus (GT) at right hand dorsum. The patient is in the supine position with the upper limb on the side table. The proximal portal (PP) and distal portal (DP) used for this procedure are placed along the extensor tendon and located at the proximal and distal ends of the tophus. The DP can be placed at the metacarpophalangeal joint level if metacarpophalangeal arthroscopy is indicated. Moreover, portal incisions should be made through the neighboring uninvolved skin instead of directly over the tophus, especially if the overlying skin is thin or invaded by the tophaceous materials. (ED, extensor digitorum tendon.) Arthroscopy Techniques 2017 6, e827-e832DOI: (10.1016/j.eats.2017.02.011) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 2 Endoscopic decompression of gouty tophus (GT) at right hand dorsum. The patient is in the supine position with the upper limb on the side table. The distal portal is the viewing portal. After dissection of the dorsal surface of the tophus, the GT and the extensor digitorum tendon (ED) are clearly seen. Arthroscopy Techniques 2017 6, e827-e832DOI: (10.1016/j.eats.2017.02.011) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 3 Endoscopic decompression of gouty tophus (GT) at right hand dorsum. The patient is in the supine position with the upper limb on the side table. The distal portal (DP) is the viewing portal. (A) The extensor tendon proximal to the tophus is identified. The interface between the tophus and the tendon is dissected out with SuperCut scissors through the proximal portal (PP). (B) The tophus is cut open by the scissors to expose the extensor tendon within the proximal part of the tumor. (ED, extensor digitorum tendon.) Arthroscopy Techniques 2017 6, e827-e832DOI: (10.1016/j.eats.2017.02.011) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 4 Endoscopic decompression of gouty tophus (GT) at right hand dorsum. The patient is in the supine position with the upper limb on the side table. The proximal portal (PP) is the viewing portal. (A) The extensor tendon is dissected from the distal part of the tophus by a retrograde knife. (DP, distal portal.) (B) The retrograde knife (RK) is placed at the interface between the tophus and the tendon, and the tendon can be dissected from the tophus by retrieval of the knife. (ED, extensor digitorum tendon.) Arthroscopy Techniques 2017 6, e827-e832DOI: (10.1016/j.eats.2017.02.011) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 5 Endoscopic decompression of gouty tophus (GT) at right hand dorsum. The patient is in the supine position with the upper limb on the side table. The distal portal is the viewing portal, and the proximal portal is the working portal. The proximal part of the GT is resected by an arthroscopic shaver (AS) with the blade facing away from the extensor digitorum tendon (ED). The debridement is performed from the tendon outward. Arthroscopy Techniques 2017 6, e827-e832DOI: (10.1016/j.eats.2017.02.011) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 6 Endoscopic decompression of gouty tophus (GT) at right hand dorsum. The patient is in the supine position with the upper limb on the side table. The proximal portal is the viewing portal. The distal part of the GT is debrided by the arthroscopic shaver (AS) through the distal portal. The debridement starts at the extensor digitorum tendon (ED) outward. Arthroscopy Techniques 2017 6, e827-e832DOI: (10.1016/j.eats.2017.02.011) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 7 Endoscopic decompression of gouty tophus at right hand dorsum. The patient is in the supine position with the upper limb on the side table. The proximal portal is the viewing portal, and the distal portal is the working portal. (A) Tophaceous material that is firmly adherent to the tendon is gently curetted. (AC, arthroscopic curette.) (B) The loosened tophaceous material is removed by the arthroscopic punch (AP). (ED, extensor digitorum tendon.) Arthroscopy Techniques 2017 6, e827-e832DOI: (10.1016/j.eats.2017.02.011) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 8 Endoscopic decompression of gouty tophus at right hand dorsum. The patient is in the supine position with the upper limb on the side table. The distal portal is the viewing portal. The extensor digitorum tendon (ED) is examined for integrity after debulking of the tophus. Arthroscopy Techniques 2017 6, e827-e832DOI: (10.1016/j.eats.2017.02.011) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions