Tophaceous gout presents three overlapping issues in the hands: pain; arthropathy; tumor. Medical management is the first line of treatment. Failing that, surgery may be beneficial. Surgery is unpredictable: tophi are not encapsulated, and can diffusely permeate tendons and other soft tissues. Debridement may demonstrate or result segmental tendon loss, and the surgical plan should include the possible need for tendon graft. Arthrodesis is preferable to arthroplasty because of the effect of particulate debris. These cases illustrate surgical excision of bulky tophaceous gout.

