Amputation of the first metatarsophalangeal joint due to a giant gouty tophi

Abstract

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.

Effects of febuxostat on serum cytokines IL‑1, IL‑4, IL‑6, IL‑8, TNF‑α and COX‑2

“…Studies have demonstrated that (8) hyperuricemia is associated with inheritance, medicine, past history of renal diseases, and intake of high purine and protein diet. When purine metabolism disorder occurs in the body, it causes overproduction and excretion reduction of uric acid in vitro at the same time (9). At this time, ~1/10 patients with hyperuricemia have uric acid deposited in the joints, soft tissues and kidneys in the form of sodium salt, which triggers inflammatory responses at the above-mentioned positions with uric acid deposition, further manifesting as gout attacks (10).…”

Year in Review: Gout Clinical Research

“…Many of these conditions are linked to an increased risk of lower extremity amputation (LEA) [40]. It is common to find reports of amputations in the context of gout, be it as comorbidity or as a postoperative diagnosis [41][42][43]. This link could be related to the comorbidities mentioned above.…”

Comparison of Rates of Lower Extremity Amputation in Patients With and Without Gout in the US Department of Veterans Affairs Health System

“…It is recognized, for example, that gout mimics infectious processes of septic arthritis, 14 cellulitis, 15 and osteomyelitis 16 and can masquerade as a nonhealing diabetic foot ulcer, 17 which is a frequent indication for LEA. 18 Numerous reports 18 , 19 , 20 , 21 , 22 have described digital and/or lower limb amputations in the context of gout, some 21 , 22 citing infection in the setting of gout, and another 19 reported a gout diagnosis made postoperatively after histopathologic examination of resected tissues. Whether patients with gout undergo LEA at a higher rate than those without gout is unknown.…”