# Reconstruction of an extensive gouty tophus ulceration at the wrist using a dermal matrix and autologous skin graft: A case report

## TL;DR

A new surgical method using a dermal matrix and skin graft successfully treated a severe wrist gout ulcer, avoiding major complications and preserving joint function.

## Contribution

A staged reconstructive approach using dermal matrix and autologous skin graft is proposed as a less invasive alternative for complex gout ulcers.

## Key findings

- The staged protocol provided durable tissue coverage and functional preservation in a 24-month follow-up.
- The approach avoided donor-site morbidity and joint stiffness associated with traditional flap surgery.
- The patient achieved recurrence-free survival and a low scar assessment score.

## Abstract

Ulcerated tophaceous gout of the wrist poses a major reconstructive challenge, owing to deep tissue infiltration by urate crystals, high infection risk, and the functional demands of the joint. Although local or free flaps are frequently used, these techniques are often associated with significant donor-site morbidity, technical complexity, and prolonged immobilization that may contribute to joint stiffness. This report presents a staged approach using a dermal regeneration matrix followed by autologous skin grafting, offering a less invasive and functionally advantageous alternative for reconstructing such complex defects.

A 60-year-old male with a 25-year history of poorly controlled, treatment-refractory tophaceous gout presented with a 7-day history of a spontaneously ruptured ulcer on the dorsoradial aspect of the wrist, measuring 8 × 5 cm. The wound exhibited three hallmark features:

1. Tendon exposure with localized tendon necrosis;

2. Active tophaceous discharge, confirmed by microscopy to contain monosodium urate (MSU) crystals exhibiting needle-shaped morphology and negative birefringence;

3. Deep tissue invasion with intraoperative evidence of radiocarpal joint involvement.

Serum uric acid levels were 630 μmol/L preoperatively (during titration of febuxostat from 40 mg to 20 mg/day) and decreased to 500 ± 15 μmol/L at 24-month follow-up.

The Patient and Observer Scar Assessment Scale (POSAS) patient score was 2/10 (one representing normal skin).

The staged reconstruction protocol, which combines dermal substitution with autologous skin grafting, delivers durable soft tissue coverage and functional preservation in complex wrist gout ulcerations. This approach represents a less morbid and technically feasible alternative to traditional flap surgery, particularly in high-risk patients with multiple comorbidities. Excellent mid-term outcomes were observed, including 24-month recurrence-free survival.