1.1.4.1. Included studies

No relevant clinical studies for surgical excision of tophi were identified.

See also the study selection flow chart in Appendix C.

1.1.4.2. Excluded studies

See the excluded studies list in Appendix J.

1.1.7.1. Included studies

No health economic studies were included.

1.1.7.2. Excluded studies

No relevant health economic studies were excluded due to assessment of limited applicability or methodological limitations.

See also the health economic study selection flow chart in Appendix G.

Effectiveness

• No relevant published evidence was identified.

Economic

• No relevant economic evaluations were identified.

1.1.11.1. The outcomes that matter most

The committee considered the following outcomes as important for decision-making: health-related quality of life, pain, patient global assessment of treatment success, cardiovascular, renal and gastrointestinal adverse event, radiographic joint damage, tophi, surgical complications (wound healing, infection), serum urate levels, admissions (hospital and A&E/urgent care) and GP visits.

The timepoints were separated by short-term (less than three months), medium-term (three to 12 months) and long-term (more than 12 months) duration.

1.1.11.2. The quality of the evidence

No clinical or cost-effectiveness evidence was identified for the surgical excision of tophi. The committee decided to make a consensus recommendation based on their clinical experience.

1.1.11.3. Benefits and harms

The committee agreed surgical excision of tophi is an uncommon procedure, and surgery is only offered to people with gout who have symptomatic tophi adversely affecting their quality of life due to pain and/or restriction of movement. The committee discussed that tophi develop very slowly over many years and typically occur in the toe, fingers, attachment of the Achilles tendon to the heel or the elbow, in people with high urate or long-standing undertreated gout.

The committee noted surgical excision is not without complications, including damage to tendons and blood vessels, infection, and reduced wound-healings. Nerve entrapment can also make removal of tophi more complicated. The committee discussed that development of tophi is seen in people with uncontrolled gout and tends to be in an older population. They agreed that treat-to-target ULT will reduce serum urate levels and shrink tophi over time. In their experience, referral to orthopaedic surgery would be rarely required.

The committee decided not to make a recommendation as there was no clinical or cost-effectiveness evidence and they did not think a consensus recommendation was appropriate because in their experience a decision to refer for consideration for surgery is rare and would only be made on an individual patient and clinician preference.

The committee discussed whether a research recommendation was required but agreed it would be very difficult to conduct research in this area due to the limited number of people that have the operation, and concluded it was not feasible and also of low priority given the few people who undergo surgery. The committee also noted that the recommendations made in this guideline, regarding urate-lowering therapy, should result in more people receiving and benefitting from effective treat-to-target ULT. This would result in fewer people being referred for surgical excision.

1.1.11.4. Cost effectiveness and resource use

No health economic studies were identified for this review. Unit costs were sought to aid consideration of cost effectiveness.

Overall, due to a lack of clinical and cost effectiveness evidence the committee did not make a recommendation for this review question. Subsequently there is not expected to be a substantial resource impact.