[Beware of misdiagnosis and incorrect treatment of acute gout flare and postoperative infections after arthroscopic surgery for knee gouty arthritis].

OBJECTIVE: To analyze the differences of clinical features of acute gout flare and postoperative infection under arthroscopy of knee gouty arthritis patients to offer guiding opinions of clinical diagnosis and treatment. METHODS: Between January 2017 and December 2022, 235 patients with gouty knee osteoarthritis were admitted, and underwent arthroscopic debridement combined with synovectomy. Among them, 35 cases had fever with a temperature higher than 38 °C postoperatively while acute inflammatory appears under redness, swelling, heat and pain of the operated joints. There were 29 males and 6 females, with an average age of (41.48±13.90) years old. Among them 23 patients were diagnosed with acute gout attack, and recovered well after being given colchicine and prednisolone;12 patients were diagnosed with postoperative joint infection, and were cured after being given anti-infective treatments and cleaning and rinsing of the joint cavity. The two groups of patients were compared and analyzed in terms of preoperative general data, surgical conditions, hematology, joint fluid, limb function and other clinical characteristics. RESULTS: There were no significant difference in the preoperative general data between two groups. The onset of fever in the postoperative acute gout flare group occurred mostly within 48 hours, significantly earlier than that in the postoperative infection group(P=0.037). The visual analogue scale score was significantly higher in the acute gout flare group (5.32±1.38) score than in the postoperative infection group (2.45±0.68) score (P=0.000), while 14 patients with acute gout flare were accompanied by severe pain in other joints. Hematologically, indicators such as white blood cell counts and ratios were significantly higher in both groups. In terms of inflammatory indicators, IL-6, erythrocyte sedimentation rate, procalcitonin and other inflammatory indicators were significantly elevated in both groups, but there was no statistical difference between two groups. The C-reactive protein level in the postoperative infection group (220.97±116.30) mg·L-1 was higher than that in the postoperative acute gout attack group(120.67±82.45) mg·L-1(P=0.006). Blood uric acid (316.55±112.84) µmol·L-1 was higher in the acute postoperative gout flare group than in the postoperative infection group (159.14±126.92) µmol·L-1(P=0.001). In the joint fluid examination of the postoperative infection group, the glucose metabolism indicator was significantly lower than that of the acute gout flare group, and five of them had positive bacterial cultures. CONCLUSION: The symptoms of acute gout flare could be mistaken as postoperative infection due to their similarity, therefore requires careful differentiation. Differential diagnosis should be based on a combination of clinical signs, hematology and joint fluid findings, and targeted treatment should be given to avoid serious complications.

Arthroscopic surgery for ankle gouty arthritis: a retrospective analysis of clinical outcomes at six month follow-up based on a novel classification system.

PURPOSE: This study aimed to evaluate the clinical outcomes, patient-reported outcomes, and recurrence rate of patients diagnosed with ankle gouty arthritis who underwent arthroscopic surgery based on the new classification. METHODS: A total of 51 patients diagnosed with ankle gouty arthritis were included in this retrospective study. A new classification was proposed based on the location and extent of MSU crystal deposition under an arthroscopy view. Patients are classified into different types and underwent arthroscopic surgery accordingly. The primary outcome measure was the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score. The secondary outcomes included the visual analog pain scale (VAS), serum uric acid levels, and the recurrence rate of ankle gouty arthritis at one year postoperatively. RESULTS: Based on the new classification, five patients were Type I, 24 patients were Type II, five were Type III A, six were Type III B, and 11 were Type IV. The average follow-up time was 23.5 ± 10.9 months. The AOFAS hindfoot-ankle score improved significantly from 70.3 ± 15.9 to 85.6 ± 13.0 (p < 0.01). The mean serum uric acid level was significantly decreased from 442.0 ± 109.2 to 540.5 ± 132.4 (p < 0.01). The average VAS scale decreased from 3.8 ± 1.9 to 1.4 ± 1.7 (p < 0.01). The median of recurrences in one year postoperatively was significantly decreased from 1.5 (1, 3.75) to 0 (0, 0.75) (p < 0.01). CONCLUSION: A new classification strategy for ankle gouty arthritis based on arthroscopic view was proposed. Patients with ankle gouty arthritis showed significant improvement in ankle function and pain relief after undergoing arthroscopic surgery driven by the new classification.

Diagnosis Dilemma, Culture-Negative Periprosthetic Hip Infection Versus Acute Gouty Arthritis: A Case Report.

CASE: We report the case of acute gouty arthritis mimicking infection in a 59-year-old woman who had an extensive history of periprosthetic joint infection (PJI) and multiple revisions. Initial laboratory testing, examination, and recency bias suggested recurrent PJI, but aspiration revealed an acute gout attack without superimposed infection. The patient's examination and serological markers improved off antibiotics, and she subsequently avoided an unnecessary revision surgery. CONCLUSION: Although rare, acute gouty arthritis should be considered in every patient, and complete workup should be performed, regardless of infectious or rheumatologic history.

The application of a novel hydrodynamic cavitation device to debride intra-articular monosodium urate crystals.

INTRODUCTION: Efficient and complete debridement of intra-articular deposits of monosodium urate crystals is rarely achieved by existing arthroscopic tools such as shavers or radiofrequency ablation, while cavitation technology represents a prospective solution for the non-invasive clearance of adhesions at intra-articular interfaces. METHODS: Simulation modeling was conducted to identify the optimal parameters for the device, including nozzle diameters and jet pressures. Gouty arthritis model was established in twelve rats that were equally and randomly allocated into a cavitation debridement group or a curette debridement group. A direct injection nozzle was designed and then applied on animal model to verify the effect of the cavitation jet device on the removal of crystal deposits. Image analysis was performed to evaluate the clearance efficiency of the cavitation device and the pathological features of surrounding tissue were collected in all groups. RESULTS: To maximize cavitation with the practical requirements of the operation, an experimental rig was applied, including a 1 mm direct injection nozzle with a jet pressure of 2.0 MPa at a distance of 20 mm and a nitrogen bottle as high-pressure gas source. With regards to feasibility of the device, the clearance rates in the cavitation group were over 97% and were significantly different from the control group. Pathological examination showed that the deposition of monosodium urate crystals was removed completely while preserving the normal structure of the collagen fibers. CONCLUSIONS: We developed a promising surgical device to efficiently remove intra-articular deposits of monosodium urate crystals. The feasibility and safety profile of the device were also verified in a rat model. Our findings provide a non-invasive method for the intraoperative treatment of refractory gouty arthritis.

Autologous osteochondral graft as treatment for gouty tophus in the talus: A case report.

RATIONALE: Gout can cause redness, swelling, local heat, severe pain, and limitation of function of the affected joints and surrounding tissues. Gouty tophi are commonly found in the auricle, joints, Achilles tendon and tarsal bursa. However, gouty tophi rarely affect the talus. PATIENT CONCERNS: We report a case of a 35-year-old man with a history of a sprained left ankle (six years before presentation), who presented with atraumatic and progressive pain, which the patient has been experiencing for a year. DIAGNOSIS: The patient was diagnosed with ankle pain with a gouty stone in the talus. INTERVENTIONS: The patient was treated with autologous osteochondral transplantation. OUTCOMES: During the two-year follow-up period, the patient's ankle joint underwent functional recovery and pain relief. Furthermore, the patient's Baird-Jackson ankle score improved from 80 to 95. LESSONS: The gold standard for the diagnosis of gouty tophus in the talus is intraoperative arthroscopy and pathology. The presented case achieved satisfactory clinical effects with autologous osteochondral transplantation as the treatment for gouty tophus in the talus, and obtained an ideal hyaline cartilage repair with restored ankle joint function.

Treatment of atypical gouty arthritis of the hip using total hip arthroplasty: A case report.

RATIONALE: Gout and gouty arthritis typically involve peripheral and monoarticular joints, especially the first metatarsophalangeal joint and knees. Hip involvement in patients with gout is rare, and its diagnosis is very difficult, especially in the late stages of the disease. Total hip arthroplasty could be a surgical treatment for atypical gouty arthritis of the hip; however, few cases have been reported. PATIENT CONCERNS: We reported an uncommon case of a 74-year-old man without typical symptoms of hip gout arthritis whom was misdiagnosed as having avascular necrosis of the femoral head. DIAGNOSES: Clinical examination and imaging revealed bilateral avascular necrosis of the femoral head. However, the final pathology report revealed left hip gout arthritis. INTERVENTIONS: The patient underwent left total hip arthroplasty and was followed up for 3years. OUTCOMES: The outcome was favorable. The function of the left hip was almost normal. LESSONS: Our case indicated the difficulty of the diagnosis of hip gout arthritis. Due to the lower rates of hip gout arthritis and lack of typical clinical examination, it is easy to misdiagnose. Furthermore, surgical treatment for the late stage of hip gout arthritis has not previously been reported. In our case, total hip arthroplasty proved to be a good option.

Bilateral Kienböck's disease concomitant with gouty arthritis.

A 38-year-old man presented with a 2-month history of pain and stiffness in the bilateral wrist. The pain in right wrist was disabling and severe enough to restrict the daily life activities. After the evaluation of clinical and radiological features, the patient was diagnosed with Kienböck's disease Lichtman stage IIIB in the right wrist and stage IIIA in the left wrist. Routine laboratory investigations revealed a serum uric acid 9.27 mg/dL. Lunate excision and scaphocapitate fusion were done in the right wrist after discussing with the patient. The histopathological examinations of tophi in synovial tissue were negatively birefringent under polarised light microscopy. It confirmed the diagnoses of gout. Febuxostat was started postoperatively. The patient returned to work at the end of 5 months. There was no recurrence of symptoms and radiological signs of arthritis at the end of 1 year.

Acute Gout Attack Immediately After Total Knee Arthroplasty: A Case Report.

CASE: We report a case of acute gouty arthritis-mimicking infection that occurred immediately after right total knee arthroplasty in a 73-year-old man. Repetitive laboratory tests showed acute inflammation and did not easily distinguish acute gout from bacterial infection. Surgical treatment was undertaken for diagnostic and therapeutic purposes. A large amount of chalky whitish crystals suggestive of acute gout was found in both knees without the suspicion of bacterial infection, and thorough irrigation and debridement were performed. CONCLUSIONS: Although conservative treatment is generally administered for acute gouty arthritis, early surgical intervention may ensure a good clinical result in a prosthetic joint.

Gouty spondylodiscitis with lumbar vertebral body retrolisthesis: A case report.

RATIONALE: Gout occurs mainly in joints, but rarely in the spine. In the spine, urate crystals can cause intervertebral space instability but rarely lead to retrolisthesis. Here, we present an extremely rare disease with gout invaded the intervertebral disc with lumbar retrolisthesis. PATIENT CONCERNS: A 61-years male patient with gout history has suffered from severe low back pain and intermittent claudication. Physical examination showed the level of muscle strength of his left first toe was 3/5. Images illustrated a destruction of the intervertebral space, and a retrolisthesis at L4/5 interspace and the dural sac obviously compressed. DIAGNOSES: Combining with lab examinations, imaging examinations, and histopathological results, the patient was diagnosed with gouty arthritis associated with lumbar spinal stenosis, L4-5 spondylodiscitis and L4 vertebral body retrolisthesis. INTERVENTION: The patient underwent posterior decompression, reduction, and interbody fusion, and then received an aggressive postoperative rehabilitation program. OUTCOMES: The patient's low back pain was significantly alleviated after the operation. Postoperative X-ray shows the internal fixation was well placed and the sequence of spine was reconstructed. 12 weeks later, the lower limb symptoms of the patients were obviously improved, his muscle strength of the left first toe was 4/5, Japanese Orthopaedic Association (JOA) score was 19 and the improvement rate was 61.5%. LESSONS: Gouty spondylodiscitis can cause intervertebral space instability. Sagittal imbalance and degeneration of disc with decreasing of segmental disc height are considered as the main factors of retrolisthesis. The appearance may lead to misdiagnose a patient with gout history with a destruction of the intervertebral space. Surgery is a compromise method for gouty spondylodiscitis patients with urgent neurological symptoms.

Gouty Tophi in Sinus Tarsi of Bilateral Feet Mimicking Synovial Sarcoma:A Case Report.

Chronic gout is defined as accumulation of monosodium urate crystals in joints, cartilage, tendons, bursae, bone, and soft tissue. The foot is the most common location for acute gout flares, with the first metatarsophalangeal joint being the most frequent site of tophus formation. However, few studies have reported gouty tophus formation in the subtalar joint. Gout has been termed the "great mimicker" because of its tendency to mimic other pathologic conditions, such as pigmented villonodular synovitis and synovial sarcoma. Herein, we present a rare case of chronic tophaceous gout in the sinus tarsi in both feet in a 23-year-old healthy male, with extensive bony erosions mimicking pigmented villonodular synovitis and synovial sarcoma. We discuss the clinical presentation, distinguishing radiologic characteristics, surgical procedures, and outcome regarding this unique presentation.

Infection of a tophaceous nodule of the wirst and hand.

Tophaceous gout occurs years after recurrent attacks of acute inflammatory arthritis. The urate deposits are incriminated in the inflammatory process; however, their infection is exceptional. We report the observation of an infected gouty tophus of the pinky and the wrist of a 40-year-old man, presented as an excruciating inflammatory pain with buff-yellow swelling of the fifth right finger and wrist in a febrile context. As a matter of fact, the evolution was favourable after surgical excision and antibiotic therapy. The infection of a tophus is an exceptional complication of the gout. In daily practice, this diagnosis is really a difficult challenge for the clinician. The systematic bacteriological examination of the tophi with cutaneous fistulation is necessary to introduce prematurely an adapted treatment.

Spinal tophaceous gout presenting in a young adult without pain.

A 26-year-old man with a medical history of gout and morbid obesity presented with a 7-day history of decreased sensation to light touch and temperature from the feet to the level of the nipples. He also noted incomplete voiding. Laboratory investigations showed an elevated serum uric acid level (10.4 mg/dL, reference range: 3.8-8.7 mg/dL) as well as negative rapid plasma reagin and rheumatoid factor. MRI showed inflammatory changes on multiple spinal levels. Laminectomy was performed, with follow-up biopsy revealing multiple multinucleated giant cells and monosodium urate (MSU) crystals. He was ultimately diagnosed with spinal gout. Patient's symptoms did not resolve immediately after surgery. Yet with the administration of intravenous glucocorticoids and a course of non-steroidal anti-inflammatory drugs, he slowly regained sensation, leaving the hospital with complete resolution of symptoms.

Bilateral First-Ray Amputation of the Foot Due to Severe Tophaceous Gout Complicated by Infection and Discharged Sinus A Case Report.

BACKGROUND: Gout is a purine metabolism disease. Tophaceous gout may cause joint destruction and other systemic problems and sometimes may be complicated by infection. Infection and sinus with discharge associated with tophaceous gout are serious complications, and treatment is difficult. We present a patient with tophaceous gout complicated by infection and discharging sinus treated by bilateral amputation at the level of the first metatarsus. METHODS: A 43-year-old man previously diagnosed as having gout, and noncompliant with treatment, presented with tophaceous gout associated with discharging sinus and infection on his left first metatarsophalangeal joint. Because of the discharging sinus associated with the tophaceous deposits, the soft-tissue and bony defects, and the noncompliance of the patient, amputation of the first ray was undertaken, and a local plantar fasciocutaneous flap was used to close the defect. After 8 months, the patient was admitted to the emergency department with similar symptoms in his right foot, and the same surgical procedure was performed. RESULTS: One year after the second surgery, the patient had no symptoms, there was no local inflammatory reaction over the surgical areas, and laboratory test results were normal. CONCLUSIONS: Gout disease with small tophi often can be managed conservatively. However, in patients with extensive lesions, risk of superinfection justifies surgical treatment. Results of complicated cases are not without morbidity; therefore, early surgical treatment may prevent extremity loss and further complications. In severe cases, especially with compliance issues, amputation provides acceptable results.

Use of Masquelet's technique for treating the first metatarsophalangeal joint in cases of gout combined with a massive bone defect.

BACKGROUND: To examine the safety and efficacy of Masquelet's technique as a surgical method for treating the first metatarsophalangeal joint in cases of gout accompanied by a massive bone defect. METHODS: From January 2010 to January 2016, eleven patients (7 males and 4 females; mean age 33.1 years; range, 23-43 years) received surgical treatment for a first metatarsophalangeal joint tophus which caused a serious bone defect. The first metatarsophalangeal bone defects ranged from 3-6cm, or nearly 50% of the length of normal bone. During the first stage of Masquelet's technique, we removed the tophus and infused that area with bone cement that contained antibiotics. Two months later, we performed the second stage, in which the prosthesis was replaced with iliac cancellous bone, and the operated area was stabilized via locking plate fixation. RESULTS: All of the surgeries were successful, and the 11 patients were followed up for an average of 10.9 months. Postoperative evaluations showed that 10 of the 11 patients healed between 9 and 14 days after the initial surgery. Bone fusion occurred between 2.3 and 3.6 months after the operation, and the average healing time was 3.0 months. One foot wound became infected, but healed after vacuum aspiration. When the American Association of Foot and Ankle Surgery Maryland Foot scoring system was used to evaluate the foot function of the 11 patients prior to surgery, all 11 patients were graded as "failures." Following surgery, 2 patients were graded excellent, 5 were good, 3 were fair, and only 1 patient failed. The total combined excellent and good rate was 63.6%. The total mean Maryland scores pre- and post-surgery were 27.8 points and 74.1 points, respectively; thus the average patient score increased by 46.3 points. CONCLUSIONS: Joints with advanced tophus nodules develop segmental bone defects. Masquelet's technique is an effective method for treating such nodules and their associated bone defects.