Intratendinous Gout Causing Carpal Tunnel Syndrome: Clinical Characteristics and Proposed Surgical Algorithm.

Background: Secondary carpal tunnel syndrome (CTS) caused by intratendinous tophaceous gout is rare. Preoperative diagnosis would be helpful and surgical management details are controversial. Methods: We conducted a retrospective review of CTS cases treated in our centre from January 2013 to December 2021. 564 carpal tunnel releases (CTR) were carried out. Twelve patients (14 wrists) had CTS related to intratendinous gout. Case records were reviewed and hand function was assessed using the Michigan Hand Outcomes Questionnaire (MHQ) and grip strength using Jamar® dynamometer. Results: All patients were male with a mean age of 51 years (SD 19.3, range 31-83). None of the patients was compliant with medication. 57% of wrists had volar swelling and 71% displayed restriction in finger motion. Surgical management apart from open CTR (14) included one or more tendon procedures. They were tenosynovectomy (3), debulking (9), and tendon excision with (2) or without reconstruction (6). FDS tendons, especially middle and ring finger, were most commonly affected, followed by FDP and FPL. Mean follow-up was 32.6 months (SD 23.7, range 12-82 months). There was a significant improvement in mean MHQ scores (41.5 (SD 20.4, range 23.9-78.6)) to postoperative (77.5 (SD 17.5, range 45.5-100.0, p < 0.001)). Conclusions: Red flag signs for intratendinous gouty CTS include male gender, history of poorly treated gout, volar wrist swelling and restriction in finger motion. The clinical outcomes of tendon debulking and excision were similar. We propose CTR with concomitant tendon debulking as the first line management, tendon excision if unsalvageable and reconstruction only if FDP or FPL is excised. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-025-01483-6.