First metatarsophalangeal joint arthrodesis for the treatment of tophaceous gouty arthritis

Developing a core outcome set for foot and ankle disorders in rheumatic and musculoskeletal diseases: A scoping review and report from the OMERACT 2022 foot and ankle special interest group session

OBJECTIVES

Foot and ankle involvement is common in rheumatic and musculoskeletal diseases, yet high-quality evidence assessing the effectiveness of treatments for these disorders is lacking. The Outcome Measures in Rheumatology (OMERACT) Foot and Ankle Working Group is developing a core outcome set for use in clinical trials and longitudinal observational studies in this area.

METHODS

A scoping review was performed to identify outcome domains in the existing literature. Clinical trials and observational studies comparing pharmacological, conservative or surgical interventions involving adult participants with any foot or ankle disorder in the following rheumatic and musculoskeletal diseases (RMDs) were eligible for inclusion: rheumatoid arthritis (RA), osteoarthritis (OA), spondyloarthropathies, crystal arthropathies and connective tissue diseases. Outcome domains were categorised according to the OMERACT Filter 2.1.

RESULTS

Outcome domains were extracted from 150 eligible studies. Most studies included participants with foot/ankle OA (63% of studies) or foot/ankle involvement in RA (29% of studies). Foot/ankle pain was the outcome domain most commonly measured (78% of studies), being the most frequently specified outcome domain across all RMDs. There was considerable heterogeneity in the other outcome domains measured, across core areas of manifestations (signs, symptoms, biomarkers), life impact, and societal/resource use. The group's progress to date, including findings from the scoping review, was presented and discussed during a virtual OMERACT Special Interest Group (SIG) in October 2022. During this meeting, feedback was sought amongst delegates regarding the scope of the core outcome set, and feedback was received on the next steps of the project, including focus group and Delphi methods.

CONCLUSION

Findings from the scoping review and feedback from the SIG will contribute to the development of a core outcome set for foot and ankle disorders in RMDs. The next steps are to determine which outcome domains are important to patients, followed by a Delphi exercise with key stakeholders to prioritise outcome domains.

Three Cases of Gouty Tophus in the Foot Treated by Resection

We encountered three cases of gouty tophus in the foot that required resection. All patients were male and aged 44-68 years at the time of surgery. The lesions were located on the great toe, second toe, and lateral malleolus and were causing ulceration and destruction of the joints. One patient had normal uric acid levels, and another patient had hyperuricemia but no history of attacks and no significant inflammatory symptoms around the gouty tophus, which was attributed to the physical containment of uric acid crystals by the gouty tophus. Given that the crystals were adherent to the surrounding fibrous tissue and cartilage surface, we resected them as far as possible to reduce the total amount of crystals and treated the remaining crystals with uric acid-lowering therapy. There were no complications at the time of surgery. The swelling and bone destruction subsided with continued medical treatment, resulting in significant improvement in quality of life. Patients with gouty tophus should be treated aggressively with medication and monitored to prevent severe joint destruction and ulceration. Excision of the nodule should be considered in cases of exacerbation.

A Rare Case of Destruction of the First Metatarsophalangeal Joint in a Patient With Gout

Gout is a crystal deposition disorder caused due to the deposition of monosodium urate crystals in joints and other tissues secondary to hyperuricemia. Podagra is the term for gout of the first metatarsophalangeal joint. In our case report, a 30-year-old male patient came to our OPD with complaints of swelling over the first metatarsophalangeal joint for one year, which was insidious in onset, localized, and had a sudden increase in size over the past three months. The patient also complained of an inability to properly wear his shoe. A plain radiograph was done, which was suggestive of an expansile lesion with the destruction of the first metatarsophalangeal joint and the erosion of the joint surface extending to the head of the first metatarsal and the proximal phalanx of the great toe. Lab investigations revealed a serum uric acid level of 10.2 mg/dl and an acid phosphatase level of 8.92 U/L. Excision of the lesion was done and a frozen section biopsy was sent intra-operatively which confirmed the presence of monosodium urate crystals. A fibular strut graft was taken to fill the defect using a square nail passing through the first metatarsophalangeal joint and a Kirschner wire was added to the interphalangeal joint to maintain the stability of the reduction. The foot was immobilized for six weeks following which the Kirschner wire was removed and range-of-motion exercises started. There was no residual deformity, and the patient responded well to the treatment.

Gout and 'Podagra' in medieval Cambridge, England

OBJECTIVE

To estimate the prevalence rate of gout and to explore the social factors that contributed to its development in the various sub-populations in medieval Cambridge.

MATERIALS

177 adult individuals from four medieval cemeteries located in and around Cambridge, UK.

METHODS

Lesions were assessed macroscopically and radiographically. Elements with lytic lesions were described and imaged using micro-computed tomography (μCT) to determine their morphology.

RESULTS

Gout was identified in 3 % of the population. Individuals buried in the friary had highest prevalence (14 %), with low prevalence rates in the Hospital (3 %) and town parish cemetery (2 %), with no cases in the rural parish cemetery. Gout was more prevalent during the 14th-15th centuries than the 10th-13th centuries.

CONCLUSION

The high prevalence rate of gout in the friary is at least partly explained by the consumption of alcohol and purine-rich diets by the friars and the wealthy townsfolk. Medieval medical texts from Cambridge show that gout (known as podagra) was sometimes treated with medications made from the root of the autumn crocus. This root contains colchicine, which is a medicine that is still used to treat gout today.

SIGNIFICANCE

This is one of the first studies to assess the epidemiology of gout in medieval England and suggests that gout varied with social status.

LIMITATIONS

Our sample size precludes statistical analysis.

SUGGESTIONS FOR FURTHER RESEARCH

Additional studies that assess the epidemiology of gout in medieval Europe is needed in order to be able to fully contextualize these findings.

Gouty Involvement of Foot and Ankle: Beyond Flares

The foot and ankle are common locations of deposition of monosodium urate (MSU) crystals, as indicated by the clinical manifestations presented by patients with gout, which are not limited to the acute inflammation of the big toe. We present a narrative literature review aimed to update the gout involvement of foot and ankle and how it affects the quality of life. Cumulative reports indicate that gout, even at the non-tophaceous stage, could cause pain, gait impairment and limit the mobility at lower limbs. These patients may present difficulties in some activities of daily living such as choosing footwear, thus leading to an impaired quality of life. Gout is a curable disease by dissolving MSU crystals but remains unclear how this could modify some of these foot and ankle manifestations, especially when structural damage has already occurred. Furthermore, a collaboration between rheumatologists and podiatrists seems helpful to understand, relieve these symptoms and improve the quality of life in gouty patients.

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.

[Lesion clearance combined with Ilizarov technique for treatment of tophi in first metatarsophalangeal joint with bone defect]

Objective

To evaluate the effectiveness of lesion clearance combined with Ilizarov technique for the treatment of tophi in first metatarsophalangeal (MTP) joint with bone defect.

Methods

Between July 2016 and June 2018, 14 cases of tophi in the first MTP joint with bone defect were treated by lesion clearance combined with Ilizarov technique. There were 12 males and 2 females. The average age was 39.3 years (range, 22-60 years). The disease duration ranged from 5 to 15 years, with an average of 11.2 years. The tophi volume ranged from 2.5 cm×2.7 cm×2.2 cm to 5.2 cm×2.9 cm×2.4 cm. The X-ray films showed that the length of the bone defect ranged from 2.0 to 4.6 cm, with an average of 3.4 cm. Preoperative visual analogue scale (VAS) score was 7.6±0.9; American Orthopaedic Foot and Ankle Society (AOFAS) score was 47.5±4.3; short-form 36 health survey scale (SF-36) score was 79.7±4.7.

Results

The incision primarily healed in 13 patients after operation. The skin necrosis at the edge of the incision occurred in 1 patient and recovered after symptomatic treatment. All 14 patients were followed up 12-16 months, with an average of 13.6 months. X-ray films showed that the first metatarsal column defects were repaired. The time of bone extension ranged from 2 to 6 weeks, with an average of 3.6 weeks. The time of bone healing ranged from 9 to 16 weeks, with an average of 11.2 weeks. During follow-up, no complication such as nerve, blood vessel, or tendon injury, needle tract infection, or stress fracture occurred. At last follow-up, VAS score was 1.4±0.5, AOFAS score was 86.6±4.8, and SF-36 score was 89.1±3.3, all of which were superior to preoperative scores, with significant differences ( t=22.532, P=0.000; t=22.702, P=0.000; t=6.124, P=0.000).

Conclusion

Lesion clearance combined with Ilizarov technique is a safe and effective method for the treatment of tophi in the first MTP joint with bone defect.

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.

Result of IOFIX (Intra Osseous FIXation) device for first metatarsophalangeal joint arthrodesis: A single surgeon's series

BACKGROUND

Arthrodesis of the first metatarsophalangeal joint (MTPJ) is a common procedure to treat significant first MTPJ arthritis. However, dorsal plates used for this have been associated with high incidence of metalwork removal. The IOFIX (Intra-Osseous FIXation) is a fixed angle device that is noted to provide a more uniform compression over a larger aspect of the fusion surfaces than a screw construct alone with the advantage of minimizing soft tissue irritation which can reduce the need for subsequent implant removal.

METHODS

Twenty one consecutive patients who underwent primary first MTPJ fusion with the IOFIX were reviewed. The mean age of the cohort was 63 years (range 47-81), with 80% female. The ratio of left to right was 9:12. The mean follow up of was 28 months (range 13.4-48.2 months). Outcomes analyzed were rate of fusion, Manchester-Oxford foot questionnaire (MOXFQ) score, patient satisfaction, improvement in the intermetatarsal angle and complications.

RESULTS

Complete fusion of the first MTPJ was achieved in twenty (95%) patients. One patient had a non union and another patient developed a delayed union. The mean preoperative MOXFQ score improved from 49.7 (95% confidence interval: 46-52) to 17.9 (95% confidence interval: 12-22), p<0.05.Improvement gained in all the domains of the MOXFQ score (walking/standing, pain and social) was statistically significant (p<0.05). Eighteen out of 21 patients (85%) were very pleased or fairly pleased with the procedure.

CONCLUSION

Early results show that the rate of fusion achieved by using the IOFIX device for the first MTPJ arthrodesis in our series was found to be comparable to other devices quoted in the literature.

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.

Amputation of the first metatarsophalangeal joint due to a giant gouty tophi: A case report

RATIONALE

The first metatarsophalangeal joint (MTP1) is the most frequent site of gouty tophi. We report an unusual case with a giant skin-perforating tophi. This is the first case of gouty tophi at MTP1 which accepts surgical debulking and amputation.

PATIENT CONCERNS

A 42-year-old man presented with a seven-year history of gout and a giant tophi at MTP1. The patient was referred to hospital due to persistent pain and ulcerations on the surface of the left MTP1. This rounded, giant, swelling, tophaceous tophi severely interfered with his normal walking.

DIAGNOSES

The patient was diagnosed with gouty arthritis seven years ago, and did not receive regular anti-gout treatments.

OUTCOMES

Biochemical examination showed he had raised serum uric acid (SUA, 11.92 mg/dl) and creatinine (258 μmol/l). There was a severe joint destruction of MTP1 by X-ray examination. We controlled the skin infection by sulbenicillin. He was given febuxostat to reduce SUA. After 3 months of treatment, SUA fell to 6.8 mg/dl. Then we performed surgical debulking of MTP1 and amputation of hallux. Surgical operations obviously relieved the pain, and improved the function of his left foot. The visual closure after amputation was good.

CONCLUSION

Surgical amputation of the gout lesion at MTP1 maximized the function, and reduced the pain of this patient. In the case of giant tophi with severe gouty arthritis or skin infections, surgical decisions need to weigh gains and losses carefully.

Ultrasound Features of the First Metatarsophalangeal Joint in Gout and Asymptomatic Hyperuricemia: Comparison With Normouricemic Individuals

OBJECTIVE

The first metatarsophalangeal (MTP1) joint is frequently affected in gout. The aim of this study was to identify ultrasound features of the MTP1 joint in people with gout and people with asymptomatic hyperuricemia compared with normouricemic controls.

METHODS

Participants with gout (n = 23) and asymptomatic hyperuricemia (n = 29), and age- and sex-matched normouricemic control participants (n = 34), underwent a gray-scale and power Doppler ultrasound assessment of bilateral MTP1 joints by a single musculoskeletal radiologist. No participants had clinical evidence of joint inflammation at the time of scanning. The static images were later read by 2 musculoskeletal radiologists for the presence of the double contour sign, tophus, erosion, effusion, synovial hypertrophy, synovitis, and cartilage thickness.

RESULTS

Compared to normouricemic control participants, participants with gout and participants with asymptomatic hyperuricemia had more frequent double contour sign (odds ratio [OR] 3.91, P = 0.011 and OR 3.81, P = 0.009, respectively). Participants with gout also had more erosion (OR 10.13, P = 0.001) and synovitis (OR 9.00, P < 0.001) and had greater tophus and erosion diameters (P = 0.035 and P < 0.001, respectively). More severe erosion and synovitis grades and a less severe effusion grade were independently associated with gout compared with asymptomatic hyperuricemia (R²  = 0.65, P < 0.001).

CONCLUSION

Urate deposition, synovitis, and bone erosion are common at the MTP1 joint in people with gout, even in the absence of flare. Although individuals with asymptomatic hyperuricemia lack ultrasound features of inflammation or structural joint changes, they demonstrate a similar frequency of urate deposition.

Surgical Management of Gout in the Foot and Ankle A Systematic Review

BACKGROUND

The surgical management of tophaceous gout has been well documented in the literature, including its effect on foot pain and disability. To date, there have been no systematic reviews assessing the quality of the literature relating to the operative management of tophaceous gout and the outcomes in the foot and ankle.

METHODS

The following electronic databases were searched (1980-2014): Allied and Complementary Medicine, Cumulative Index to Nursing and Allied Health Literature, MEDLINE, Scopus, and the Cochrane Library. The articles identified were published in English and included adult participants (age ≥18 years) with diagnosed gout and surgical intervention to the foot and ankle. The Downs and Black Quality Index was modified to assess the quality of the articles being reviewed.

RESULTS

Six articles were reviewed and were of moderate quality (mean quality score of 71%). Surgical management was conducted on men (88%) with a mean age of 52 years. There was wide variation in the types of surgical procedures performed, with 28% of studies reporting surgery to the first metatarsophalangeal joint. Most studies were retrospective. A wide range of outcome measures were reported: foot pain, function, preoperative and postoperative activity levels, monitoring of uric acid levels, and patient satisfaction after surgery.

CONCLUSIONS

The review demonstrated a limited number of good-quality studies. Several surgical procedures for the foot and ankle in people with chronic tophaceous gout were reported. Future studies should include prospective observational studies using validated and reliable patient-reported outcome measures.

The first metatarsophalangeal joint in gout: a systematic review and meta-analysis

Background

The aim of this review was to qualitatively synthesise studies that have investigated characteristics of the first metatarsophalangeal joint (1^st MTP) in gout and to undertake a meta-analysis to estimate the average prevalence of acute 1^st MTP arthritis across studies in people with gout.

Methods

Studies published in English were included if they involved participants who had a diagnosis of gout and presented original findings relating to the following outcome measures associated with the 1^st MTP: epidemiology; clinical features; structural and functional characteristics; and microscopic and imaging features.

Results

Forty-five studies were included in the qualitative synthesis. 1^st MTP pain was a prominent feature in people with gout. People with 1^st MTP gout reported walking- and general-disability. Structural and functional characteristics of 1^st MTP gout included hallux valgus, osteoarthritis, and restricted joint motion. Successful crystal aspiration ranged from 81 to 91 % and positive crystal identification via microscopy ranged from 83 to 93 % in patients with a history of 1^st MTP gout. Imaging features were common at the 1^st MTP including the double contour sign, tophi and erosions. Eleven studies involving 2,325 participants were included in the meta-analysis, providing an estimate of the average prevalence of acute 1^st MTP arthritis across studies of 73 % (95 % prediction interval 40–92 %; range 48–97 %; I² = 93 %).

Conclusions

1^st MTP acute arthritis is highly prevalent in people with gout and has a substantial impact on patient-reported pain and disability. Gout affects the structure and function of the 1^st MTP. Microscopic and imaging studies have demonstrated crystal deposition and joint damage at the 1^st MTP in people with gout.

Treatment of tophaceous gout: When medication is not enough

OBJECTIVES

To review the literature concerning surgical intervention of tophaeceous gout and propose clinical circumstances for when it may be considered.

INTRODUCTION

Tophi develop in approximately 12-35% of patients with gout. Tophaceous disease is usually preventable given the availability of effective urate lowering therapies (ULT) including allopurinol, febuxostat, probenecid, lesinurad, and pegloticase. Despite medical therapy, there remains a subset of patients who develop significant complications of tophi including infection, ulceration, and entrapment neuropathy. Tophi in close proximity to joints can cause joint instability, severely limited range of motion, and significant functional impairment. For the rare circumstance when a tophus is causing an urgent complication or if a patient has a contraindication to all available ULTs, surgery may be an appropriate option. This review summarizes the published experience with surgical interventions for tophaceous gout and offers recommendations for its consideration.

METHODS

Using Medline and Google Scholar, all available series of surgery for tophaceous gout were reviewed.

RESULTS

Overall, 7 published surgical series were identified. In all, 6 of these 7 series were published between 2002 and 2014. The reported outcomes of surgical interventions for tophaceous gout were generally positive without major post-surgical complications.

CONCLUSION

Although medical therapy with ULTs should be the first-line approach to tophaceous gout, surgery should be considered for the rare patient with impending or severe, debilitating complications including infections, entrapment neuropathy or those at risk for permanent joint destruction. In these selected clinical circumstances, surgical intervention for tophaceous gout may be appropriate.

The gouty tophus: a review

The tophus is the cardinal feature of advanced gout. This review summarises recent research into the biology, impact and treatment of tophaceous gout. Microscopically, tophi are chronic foreign body granuloma-like structures containing collections of monosodium urate (MSU) crystals surrounded by inflammatory cells and connective tissue. Extracellular trap formation mediated by neutrophil interactions with MSU crystals may be a central checkpoint in tophus formation. Gouty tophi impact on many aspects of health-related quality of life. Tophi are also implicated in the development of structural joint damage and increased mortality risk in people with gout. Effective treatment of tophaceous gout requires long-term urate-lowering therapy, ideally to achieve a serum urate concentration of <5 mg/dL (300 μmol/L). Recent advances in gout therapeutics have expanded urate-lowering therapy options for patients with severe tophaceous disease to allow faster regression of tophi, improved health-related quality of life and, potentially, improved structural outcomes.