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Gouty tophi are a clinical manifestation of hyperuricemia in advanced stages. They can produce pain, functional limitation, and severe deformities. Patients with severe symptoms require short-term symptomatic solutions that standard medical management is not able to provide. The objective of this study was to present the results obtained with the surgical management of tophaceous gout in the upper limb, as well as present a detailed characterization of the disease in the upper limb. Databases of the hand surgery service of a quaternary care hospital were reviewed to identify patients aged >18 years old undergoing tophi resection in the upper limbs between 2014 and 2020. Medical history records were reviewed retrospectively, and the relevant data were extracted to establish demographic profile, clinical presentation, anatomic distribution, postoperative outcomes, and additional procedures required. The most frequent symptom was pain (83%), followed by limited range of motion (56%), deformity (50%), and daily living/occupational activity limitation (28%). The main indications for surgical management were the presence of deformity, pain, and/or limited range of motion. The most frequently affected anatomic sites were the metacarpophalangeal joints, followed by the elbows, proximal interphalangeal joints, and proximal phalanges. The postoperative complication rate was 28%. The most common complications were operative site infections and wound dehiscence. Decreased pain was associated with surgical resection. Additional procedures, such as extensor tenorrhaphy and local flaps, were required in 47.2% of patients. Surgical resection of tophi can decrease pain. Although surgery is associated with a high rate of complications, most are minor. Therapeutic IV. [ABSTRACT FROM AUTHOR]

Gout is currently the most frequent cause of inflammatory arthritis worldwide. It results from elevated serum urate and subsequent deposition of monosodium urate crystals in joints and other tissues. While many patients with gout can be managed with conventional agents (e.g., allopurinol, febuxostat), those with chronic refractory gout often fail to achieve treatment goals with these agents. Pegloticase is a recombinant, pegylated mammalian uricase developed for treatment of chronic refractory gout. Pegloticase is different than other urate lowering therapies in that it enzymatically degrades urate. Pegloticase has been evaluated in multiple studies, most importantly in two randomized controlled trials and a follow-up open-label extension. Extensive analysis of results from these studies has shown that pegloticase profoundly lowers serum urate, resolves tophi, reduces tender and swollen joint counts, decreases pain, and improves both patients' global assessments and quality of life. Pegloticase also significantly decreases blood pressure in patients with chronic refractory gout, but has no significant effect on renal function. Post hoc analyses of clinical results also indicated that chronic refractory gout patients not achieving sustained urate lowering still have significant clinical benefits with pegloticase treatment. The major limitation of pegloticase is immunogenicity and the emergence of anti-drug antibodies that result in increased drug clearance, loss of efficacy, and infusion reactions. However, these reactions can be avoided by stopping pegloticase when there is a loss of serum urate lowering. New dosing regimens and co-administration of immunosuppressive agents are also being employed to overcome this limitation and extend the benefits of pegloticase to a larger number of patients. [ABSTRACT FROM AUTHOR]

Ultrasound lesions of gout have been described in people with asymptomatic hyperuricemia. However, the anatomical sites and ultrasound lesions most frequently involved in asymptomatic hyperuricemia have not yet been established. This systematic review and meta-analysis aimed to determine the prevalence of the Outcome Measures in Rheumatology (OMERACT) elementary ultrasound lesions of gout (double contour, aggregates, tophus, erosion) at various sites in people with asymptomatic hyperuricemia and to determine which sites and lesions discriminate from people with normouricemia. A systematic search of electronic databases, conference abstracts and reference lists was undertaken. Studies were included if they used ultrasound to image people with asymptomatic hyperuricemia and reported ≥1 OMERACT-defined lesion of gout. Meta-analyses were undertaken for the pooled prevalence of site-specific lesions in people with asymptomatic hyperuricemia, and the pooled odds ratios of these lesions compared to people with normouricemia. Twenty studies were included. The most common site scanned was the first metatarsophalangeal joint (1MTP) (n = 17 studies) and the most common lesion reported, the double contour (n = 18). Meta-analyses of pooled prevalence showed 1MTP double contour was the most frequent finding in people with asymptomatic hyperuricemia (0.31, 95% confidence interval (CI) 0.20–0.42), followed by femoral condyle double contour (0.16, 95%CI 0.08–0.24) and 1MTP tophus (0.16, 95%CI 0.03–0.29). The highest pooled odds ratios for asymptomatic hyperuricemia vs. normouricemia were 6.98 (95%CI 3.14–15.57) for 1MTP double contour, 13.67 (95%CI 5.42–34.49) for femoral condyle double contour and 6.10 (95%CI 1.55–24.04) for 1MTP tophus. In people with asymptomatic hyperuricemia, scanning of the 1MTP and femoral condyle for double contour, plus the 1MTP for tophus, has the highest prevalence and discrimination compared to those with normouricemia. [ABSTRACT FROM AUTHOR]

Résumé Membranes synoviales, bourses séreuses et gaines ténosynoviales sont étendues autour des articulations et des tendons de l’ensemble de notre organisme. Vascularisées, elles sont exposées aux inflammations de toutes sortes et le rhumatologue est au fait des infections, des inflammations spécifiques comme celle de la sarcoïdose mais aussi de la polyarthrite rhumatoïde et de la goutte. Cependant, certaines affections rares peuvent aussi se développer dans les articulations au détriment du tissu synovial, ou des bourses et gaines synoviales péritendineuses. Le "pot-pourri" de tumeurs bénignes, de malformations vasculaires ou de troubles de l’hémostase, etc. sera discuté dans cette brève revue. Abstract Synovial membranes, bursas and tenosynovial sheaths are lying around joints and tendons overall. Since there are vascularized, various types of inflammation can involve these structures. Rheumatologist will have to handle such infectious, or inflammatory, specific processes such as sarcoidosis, rheumatoid arthritis and gout. Moreover rare diseases can also develop with synovial tissues or bursas. A potpourri of various disease such as benign tumors, vascular malformations and hemostasis disorders, etc, will also be discussed in this short review. [ABSTRACT FROM AUTHOR]

Résumé Le genou est souvent atteint dans l’évolution des arthropathies microcristallines. La goutte et ses dépôts tophacés atteignent le genou dans l’évolution de la maladie qui débute au pied ou à la cheville. Des accès aigus typiques sont possibles, au même titre que des dépôts tophacés de la trochlée, des tendons rotulien et quadricipital. De possibles fractures de rotule sur tophus sont une complication rare mais de localisation très caractéristique. Pour le rhumatisme à pyrophosphate de calcium, les arthrites aiguës sont l’apanage du sujet âgé. Les dépôts d’apatite, sel de phosphate de calcium, sont possibles en tout site d’enthèse autour du genou, avec la même expression clinique qu’à l’épaule par exemple, depuis les anomalies radiographiques asymptomatiques jusqu’à la périarthrite aiguë. Les dépôts calciques des ménisques, du cartilage hyalin fémorotibial et de l’articulation péronéo-tibiale supérieure, peuvent être de composition variable, mélange en proportion variable de cristaux de pyrophosphate de calcium et de phosphate de calcium, et donnent lieu au concept de chondrocalcinose, simple description radiographique. Récemment des arthrites microcristallines sur prothèse totale de genou ont été décrites et posent la question d’une prothèse infectée. La clé diagnostique est à l’examen du liquide articulaire. The knee joint is frequently involved with crystal-associated deposits and arthritis. Gout and tophaceous deposits can involve the knee joint and periarticular structures, at any time over the disease progression. Typical acute flares as well as tophaceous deposits at the trochlea surface, in patellar and quadricipital tendon can occur. Fracture of the patella is a rare complication of patella tophus. Acute arthritis related to calcium pyrophosphate (CPP) crystals is the hallmark of the elderly. Apatite deposits, related to basic calcium phosphate (BCP), might occur in any enthesitic site around the knee joint. Clinical symptoms are similar to those observed at the rotator cuff, from asymptomatic deposits to acute periarthritis. By contrast calcium crystal deposits in menisci, hyaline cartilage and upper tibiofibular joint can be formed by CPP or BCP crystals, in various proportions, and lead to chondrocalcinosis, a pure radiographic description. Recently crystal-induced arthritis has been described at knee joint prosthesis with septic prosthesis as differential diagnosis. [ABSTRACT FROM AUTHOR]

Gout is a painful arthritic condition that affects many people worldwide. The disease has been associated with hyperuricaemia and life style risk factors such as obesity, alcohol intake, meat and seafood consumption. We present a case of a 67-year-old male with a history of gout, who attended the clinic with a painful 1st metatarsophalangeal joint, which had progressively worsened in pain, mobility and deformity in the last 20 years. Although lifestyle changes had been advised by the GP some years earlier such as a low purine based diet, management had only consisted of NSAID's, which had not significantly improved symptoms. Surgical excision of chalky white material from around the 1st metatarsophalangeal joint rendered the patient symptom free with increased mobility after 6 weeks. Histopathology confirmed the excised tissue as gouty tophus. Following this, the patient was placed on allopurinol, a xanthine oxidase inhibitor to prevent recurrent attacks. This case study highlights the importance of early recognition and prophylactic management in gout sufferers. In joints where the disease process is well-established surgical excision of the gouty tophus may help mitigate further disease progression, and restore quality of life to individuals. [ABSTRACT FROM AUTHOR]

Copyright of Journal of Taibah University Medical Sciences is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Résumé: Les trois types de microcristaux pathogènes chez l’homme sont susceptibles de se déposer dans les structures discales, du rachis cervical aux interlignes coccygiens. Il s’agit donc des cristaux uratiques dans la goutte, maladie sévère et tophacée habituellement connue du patient, et des cristaux de pyrophosphate de calcium dans la maladie à dépôts du même nom, et de phosphate de calcium, souvent résumés sous le terme d’apatite, dans diverses maladies. La pathogénie des dépôts discaux est de générer des réactions inflammatoires aiguës de sémiologie bien connues, parfois fébriles, et des lésions destructrices, érosives au plan radiographique. Dans ces expressions cliniques, le diagnostic positif est souvent difficile et doit souvent être assuré par un prélèvement histopathologique pour ne pas méconnaître les diagnostics différentiels, infection et tumeur. Les aspects IRM sont toutefois particuliers : hyposignaux en séquences T1 et T2, voire hyposignal T1 et hypersignal T2, avec rehaussement partiel sous Gadolinium. Le traitement de l’accès inflammatoire est celui de tout accès aigu microcristallin, et la mise en route ou l’ajustement d’un traitement hypouricémiant chez le sujet goutteux. Des arthrodèses sont parfois complémentaires des levers de compressions médullaires chez certains malades goutteux. [Copyright &y& Elsevier]

La goutte est le plus courant des rhumatismes inflammatoires de l’adulte et sa fréquence n’a cessé d’augmenter ces dernières années, dans les pays occidentaux notamment. Le pharmacien a un rôle important à jouer dans le suivi du traitement et le rappel des règles hygiéno-diététiques indispensables. [ABSTRACT FROM AUTHOR]

To describe the frequency, clinical presentation and understand the pathophysiology of toe shortenings during urate-lowering treatment (ULT) of gout, a feature we called the shrinking toe sign. Sequential foot photographs and radiographs of 1141 consecutive gouty patients followed-up for at least 6 months under ULT were retrospectively scrutinized. Features from patients with toe shortenings were extracted from anonymized files. Tophi adjacent to the shortening sites were semi quantified on foot photographs and toe shortenings were measured on radiographs with the Corel draw software (Corel corporation, Canada). Measurement concordance was assessed by concordance correlation coefficients (CCC) and correlation between tophus scores and toe shortenings was analyzed by using linear model with a patient random effect. 97 patients who did not develop toe shortening during ULT were analyzed as controls. Shrinking toes were observed in 10 patients (0.9%) with tophaceous gout at joints with baseline destructive arthropathy. The first and second toes and metatarsophalangeal joints were predominantly involved. The sign was observed after serum urate had been lowered below the 300 and 360 µmol/l targets, in 8 and 2 patients, respectively. Measured shortenings (CCC: 0.99) correlated (p < 10−4) with decreases in tophus score (CCC: 0.91). Sequential radiograph analysis revealed that toe shortening was mainly due to lytic bone collapse during articular tophus dissolution. Comparison with controls showed that the sign developed in severe gout and in joints with more severe erosion score at baseline. The shrinking toe appears as rare feature of severe tophaceous gout, triggered by dissolution of bone-replacing tophi. Our findings reinforce the need to treat gout early, before destruction of bone scaffold by extensive tophi, as MSU crystal dissolution by ULT may further weaken these areas and induce their collapse. [ABSTRACT FROM AUTHOR]

Summary: Objectives: Gouty arthritis results from the deposition of monosodium urate crystals in synovial spaces. The literature shows that a tophus may require surgical treatment to improve cosmesis or function, to alleviate pain, to eradicate sinus drainage or to remove large urate deposits. However, forceful curettage to remove tophus particles embedded in the thin attenuated skin flap may compromise blood circulation and cause other complications. This series presents the experience of the authors in performing intra-lesion shaving during the surgical treatment of tophus patients. Methods: This study analysed 147 surgical procedures performed in 108 patients with chronic tophus at a single hospital during November 2000 to July 2010. All patients underwent a soft-tissue shaver-assisted intra-lesion excavating technique developed by the authors. Bimanual palpation of the skin was performed to avoid trauma to the skin envelope. The shaving technique proved to be a simple and efficient method of reducing the total urate burden in the body. Results: Compared to conventional surgical treatment, the shaver technique is a safer and more effective option for treating tophus lesions. In this series, wound cultures were positive in 18.4% of operations. Patients with positive wound cultures and chronic renal impairment had significantly longer hospital stays compared to patients with negative wound cultures and patients without chronic renal impairment (P = 0.0019 and P = 0.0045, respectively); patients with C-reactive protein (CRP) <5 mg l−1 and white blood cell (WBC) count <10,000 μl−1 had significantly shorter hospital stays compared to patients with CRP >5 mg l−1 and WBC >10,000 μl−1 (P = 0.0002 and 0.006, respectively). The upper extremities group and the upper-lower extremities group had significantly shorter hospital stays compared to the lower extremities group (P = 0.001 and P = 0.0014, respectively). Conclusions: Medical treatment to control hyperuricaemia is important for reducing the risk of an acute attack of tophus formation. However, the data in this series show that surgery should be performed before the skin becomes ulcerated and before the tophus mass becomes infected. The proposed shaver technique markedly reduces tophus of the extremities with minimal surgical complications. [Copyright &y& Elsevier]

Objectives: Gout is typically described as an inflammatory arthropathy that affects the peripheral joints. Our aim was to describe atypical and rare clinical presentations of gouty tophi to help increase physician awareness and aid in patient care. Methods: The relevant English literature of unusual gout manifestations was searched using the keywords gout, toph*, monosodium urate, uric acid, unusual, and rare. Well-described case reports, case series, and review articles were evaluated and included, if relevant, in the literature review. Results: Review of the literature revealed many unusual manifestations of gouty tophi involving the head and neck, skin, viscera, bones, tendons, ligaments, nerves, and axial skeleton. Transplant recipients, women, and elderly people are particularly susceptible to developing tophi. Furthermore, gout can cause diagnostic dilemmas, as it can be a great mimicker of and can coexist with infection, malignancy, and other connective tissue diseases. Imaging modalities can help detect tophi in atypical locations. Conclusions: Tophi can present in unexpected locations, even as the first sign of gout, and vigilance is required when unusual symptoms or signs occur in a patient with gout. [Copyright &y& Elsevier]

The article discusses the cutaneous manifestations of diabetes in older people. One of the benefits of early diagnosis and treatment of gout is a decline in morbidity. Among the major types of calcinosis cutis are dystrophic, metastatic and iatrogenic. Also noted is the role of hyperthyroidism in pretibial myxedema.

Copyright of Revue du Rhumatisme Monographies is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The following case is an interesting presentation of gout and its long-term affects in a diabetic individual. The patient initially presented with ankle pain and, after radiographic examination, a suspicious lytic lesion in the talus and a fracture of the medial malleolus were identified. A full workup with bone biopsy was undertaken and, although the patient did not present in the typical fashion, gout was ultimately diagnosed. Based on our experience with this patient, we recommend that gout be included in the list of differential diagnoses in diabetic patients with ankle pain and radiographic evidence of articular and bone destruction. The diagnosis and treatment of gout are addressed in this paper as well. Level of Clinical Evidence: 4 [Copyright &y& Elsevier]

The article focuses on the clinical diagnosis of gout. According to the author, risk factors for gout include family history, older age, renal insufficiency and use of medication that reduces urate excretion. Among the symptoms of the condition are pain, redness and swelling peak in one day. Tips on how practitioners can correctly diagnose the condition are presented.

Abstract: The natural history of recurrent uric acid deposition includes joint destruction, as well as tendon weakening and rupture. Simultaneous rupture of the peroneus longus and brevis tendons secondary to tophaceous gout is very rare. In the present report, we describe the case of a 37-year-old man who had a history of recurrent ankle pain and 4 previous episodes of acute gout localized to his ipsilateral first metatarsophalangeal joint. The physical examination revealed the ankle pain to actually be localized to the peroneal tendons immediately distal to the fibular malleolar groove. Magnetic resonance imaging showed longitudinal tears in the peroneus longus and brevis. Surgical exploration and repair of the ruptured tendons revealed the presence of monosodium urate deposition within the substance of the tendons at the rupture sites. The tendons were debrided and repaired using longus to brevis tenodesis. The postoperative course was unremarkable and entailed referral to a rheumatologist for metabolic management. After more than a 1-year period of follow-up, the patient was ambulating without difficulties wearing regular shoe gear. [Copyright &y& Elsevier]

Abstract: In the field of wound care, the management of nonhealing wounds requires particular attention. Biopsy is often performed in such cases to rule out underlying malignancy; however, the differential remains broad. In the following case, we discuss a nonhealing post traumatic wound in a diabetic patient, secondary to unrecognized tophus. [Copyright &y& Elsevier]

Abstract: Tophi deposition is a well-recognized complication of chronic gout, but usually lacks obvious symptoms. Magnetic resonance imaging (MRI) findings may allow a relatively specific diagnosis to be rendered. In this study, we report an unusual case of gouty tophi presenting as an intra-articular synovial tumor of the knee, blocking the range of motion. We also describe its MRI appearance, which was compatible with the clinical suspicion. After arthroscopic excision of the “tumor,” the patient was symptom free. [Copyright &y& Elsevier]