Multidisciplinary expert consensus on tophus damage grading and surgical treatment (2025 edition)
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摘要: 痛风石是晚期痛风的严重并发症,痛风患者中发生痛风石的患者占12%~53%。痛风石引发的骨骼、关节损伤及慢性难愈合创面的治疗给临床带来巨大挑战。目前针对该病症的最佳手术时机、围手术期管理及治疗方案尚未形成统一标准。为此,中国医师协会创面修复专业委员会组织创面修复科、整形外科、骨与关节外科、风湿免疫科、影像科、护理与创面管理高级别专家,以文献证据为基础,结合专家意见,根据名义群体法和德尔菲法,首次确定了痛风石损害程度1~4级的分级标准和治疗原则,确保外科治疗的同质性；提出14条关于痛风石诊断和治疗的推荐意见,为痛风石的外科治疗提供了实用性指导。Abstract: Tophi, a severe complication of advanced gout, develop in approximately 12% to 53% of patients with gout. The treatment of bone and joint damages and chronic refractory wounds caused by tophi presents considerable clinical challenges. Currently, there is no unified standard for the optimal surgical timing, perioperative management, and treatment approaches for this condition. To address this, the Wound Repair Professional Committee of Chinese Medical Doctor Association convened a multidisciplinary panel of senior experts in wound repair, plastic surgery, orthopedics & joint surgery, rheumatology and immunology, radiology, and nursing and wound management. Based on the literature evidence combined with expert opinion, the panel employed nominal group and Delphi methods, and a grading standard (levels 1 to 4) defining the extent of tophi damage and the treatment principle were established for the first time to ensure homogeneity of surgical treatment; 14 recommendations on the diagnosis and treatment of tophi were proposed, providing practical guidance for the surgical treatment of tophi.
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Table 1. 2009版牛津大学循证医学中心证据分级标准
证据等级 具体描述 1a级 同质RCT系统评价 1b级 单个RCT（窄可信区间） 1c级 全或无的病例报告,如传统治疗全部无效,系列病例报告全部死亡或存活 2a级 同质队列研究的系统评价 2b级 单个队列研究（包括低质量RCT,如随访率<80%的RCT） 2c级 结果研究、生态学研究 3a级 同质病例对照研究的系统评价 3b级 单个病例对照研究 4级 病例系列研究（包括低质量队列研究和病例对照研究） 5级 基于经验,未经严格论证的专家意见 注：RCT为随机对照试验 
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Table 2. 不同损害级别的痛风石的特征和治疗原则
级别 特征 治疗原则 1级 单纯皮下痛风石,无功能受限,影像学检查显示单钠尿酸盐沉积 根据痛风指南进行规范降尿酸治疗及生活方式管理 2级 降尿酸治疗效果不佳,皮下痛风石影响日常生活,轻度关节活动受限,肌腱、韧带、骨或关节轻度损害 加强降尿酸治疗、依从性教育和随访,必要时选择手术治疗,清除痛风石,避免损害扩大,尤其是合并神经受压、感染或溃疡时 3级 慢性疼痛伴中重度关节活动受限,部分肌腱损害（连续性存在）,关节面广泛受损及骨明显破坏 进行减容手术改善外观和功能,尽可能恢复关节功能,维持关节稳定；术后功能康复锻炼 4级 终末期的关节僵硬或畸形,全部肌腱损害或形态消失,骨严重破坏（如病理性骨折） 进行减容手术和关节重建（关节融合术、植骨术、关节成形术）,对无法保留的趾或指进行截除术,术前应审慎评估共病、并发症风险
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