Intraosseous Gouty Tophus in the Talus: A Case Report

Intraosseous Gouty Osteolytic Lesion in Calcaneus

Tophaceous gout often occurs in soft tissues, and gouty invasion to the bone is rare. To date, only one case of isolated intraosseous gouty invasion to the calcaneus has been reported. We report here a rare case of an intraosseous calcaneal gouty cystic lesion treated with curettage and allogenous and autogenous bone graft. Satisfactory function and pain relief were obtained at 12-month follow-up, without any evidence of recurrent disease.

Beyond Medical Treatment: Surgical Treatment of Gout

PURPOSE OF REVIEW

Medical treatment with urate-lowering therapy (ULT) is efficacious. A recent publication suggested that surgery in gout is more prevalent than previously reported. This revelation led us to review what is known about surgical treatment of gout.

RECENT FINDINGS

The Google Scholar database (January 1, 2014-January 1, 2020) found 104 publications with a total of 169 gout patients, with an average disease duration of 6.7 years. Most (68%) were not on ULT. The mean pre-operative serum urate levels were 9.19 mg/dL. One hundred thirteen patients underwent tophi excision, while in 33 patients, tophi were found during surgery. The majority of the surgeries were performed in Asia and Europe. Most patients were not taking ULT at the time of surgery, leading to hyperuricemia. This can result in tophi reformation post-surgery. The role of surgery should be a last-line treatment and until recently has only been demonstrated through case reports.

Osteochondral lesion of talus with gout tophi deposition: A case report

BACKGROUND

Osteochondral lesion of talus is a broad term used to describe an injury or abnormality of the talar articular cartilage and adjacent bone. It arises from diverse causes, and although trauma is implicated in many cases, it does not account for the etiology of every lesion. Gout is a chronic arthritic disease caused by excess levels of uric acid in blood. Intraosseous deposition of monosodium urate in the clavicle, femur, patella and calcaneus was reported previously. Gout is common disease but rare at a young age, especially during teenage years. Osteochondral lesion caused by intra-articular gouty invasion is very rare.

CASE SUMMARY

We encountered a rare case of a 16-year-old male who has osteochondral lesion of the talus (OLT) with gout. He had fluctuating pain for more than 2 years. We could see intra-articular tophi with magnetic resonance image (MRI) and arthroscopy. We performed arthroscopic exploration, debridement and microfracture. Symptoms were resolved after operation, and bony coverage at the lesion was seen on postoperative images. We had checked image and uric acid levels for 18 mo.

CONCLUSION

It is rare to see OLT with gouty tophi in young adults. While it is challenging, the accuracy of diagnosis can be improved through history taking, MRI and arthroscopy.

Intraosseous Tophaceous Gout in Hallux Mimicking a Bone Tumor in a Young Patient: A Case Report

CASE

A 17-year-old man experienced night pain in his right hallux. Radiographs revealed a lytic lesion in the proximal phalanx of the right hallux. Magnetic resonance imaging showed a low-signal intensity mass on T1-weighted sequences and isointense-high-signal intensity on T2-weighted sequences. We suspected a benign bone tumor such as osteoid osteoma or a bone cyst and consequently performed biopsy and surgical treatment. The lesion was filled with a whitish chalk-like substance, and pathologic examination revealed tophaceous gout.

CONCLUSIONS

It can be difficult to distinguish intraosseous tophaceous gout from other diseases, including bone tumors, using imaging; hence, pathological examination may be necessary for the diagnosis.

Metabolic characteristics and renal dysfunction in 65 patients with tophi prior to gout

Tophi typically occur many years after uncontrolled gout. Therefore, their development before gout remains unusual. Such patients might exhibit some characteristic differences compared with typical tophaceous gout patients. In this study, 65 tophaceous gout patients with tophi as the first sign of gout (tophi-first group) were enrolled. Their clinical characteristics were compared with those of 1421 patients whose tophi occurred after gout (tophi-after group). Compared with the tophi-after group, the tophi-first group had a significantly higher percentage of female patients and patients with elderly onset of disease and a lower percentage of patients with a positive family history; these patients had lower body mass indices, serum urate levels, and estimated glomerular filtration rates (eGFRs). Female sex and negative family history were identified as the principal determinants of tophi development before gout. The decreasing eGFR among the tophi-first group was not due to the group per se but was a result of older age, longer tophi duration, and hyperuricemia. The most common site of initial tophi occurrence in both groups was the toe. In the tophi-first group, the occurrence rates for initial tophi sites were significantly higher at the finger but were lower at the ankle. The tophi-first group exhibited distinct characteristics of age, gender, family history, BMI, serum urate levels, and initial tophi site. This group had fewer comorbidities but similar renal dysfunction compared with the tophi-after group. Thus, patients presenting with tophi should be treated promptly, even if they have no history of gout symptoms.