Last week I performed surgery on a patient for gout. Well, for a gouty tophus actually. Gout is a metabolic disease that requires pharmacological treatment and diet changes, not surgery.

Surgery is, however, indicated for the symptoms that go along with gout. First I will tell you a little about gout in layman’s terms, then I’ll discuss complications of gout in the foot and finally gout surgery.

What is gout?

Gout is a metabolic disorder in which there is too much uric acid in the blood. This can come from: taking in too much protein that is broken down into uric acid; the kidney not being able to process enough uric acid to excrete it in the urine; and thus uric acid builds up in the blood, or less commonly, the body producing too much uric acid.

Uric acid in the blood comes from the breakdown of purines from our diet. Purines are part of proteins and are more abundant in some foods than others. The biggest offenders are shellfish, organ & red meat and legumes (beans). Alcohol intake competes in the kidney and makes the kidney excrete less uric acid than normal.

Once we intake protein, it is converted to purines and pyrimidines and the purines are further broken down in uric acid and other byproducts. The uric acid is removed from the blood by the kidney. When not enough uric acid is removed, it builds up.

High uric acid alone does not cause symptoms, however, it can effect the kidney. Being a podiatrist, I’ll skip the systemic effects of gout and talk about the manifestations in the foot.

What is an acute gout attack?

An acute gout attack in the foot occurs when the uric acid comes out of the blood and into the joints, usually the great toe joint of the foot.

If you think real hard and try to remember back to high school chemistry, a liquid can only hold some amount of a solid dissolved in it. Once it reaches its saturation point, it cannot hold any more.

Another fact about solids dissolved in liquids is that a warmer liquid can hold more solid dissolved in it than the same liquid when it is cold. Picture dissolving sugar in hot coffee which goes pretty easy, versus trying to dissolve sugar in cold water.

Going back to gout and stop reminiscing about high school, uric acid is the solid and blood is the liquid. When the blood gets further away from our core and into the extremities, it gets cooler. The warmer blood that was holding all of that uric acid dissolved in it can no longer hold all of it. For unknown reasons, the uric acid then comes out of the blood and into the joints as a solid in the form of a solid crystal.

These uric acid crystals are called negative biorefringent crystals because of how they reflect light when looked at under a microscope, but that goes beyond the scope of this article.

When these uric acid crystals enter the joints the fun begins. The body mounts a major immune response as these crystals are not supposed to be in there and are looked at like a foreign body. This is what is called the acute gout attack.

Symptoms of an acute gout attack are usually severe pain in and around the joint. The joint appears angry. It gets red, hot and swollen. Any light touch or motion hurts. Many people tell me that the pain starts at night and just the pressure from the bed sheets hurts.

Often people present with symptoms that mimic an injury but cannot recall any trauma. Often gout is also confused with the red, hot swollen symptoms of infection but there is no open sore or injury where bacteria can get in.

Making the diagnosis of acute gout attack:

Most of the time I diagnose gout based on history and symptoms. Again, red, hot swollen, painful foot joints without history of trauma or infection. Most acute gout attacks occur in the great toe joint and other joints of the foot and ankle. The next most common joint affected is the knee, however, gout can occur in any joint in the body.

Most of the time when I suspect gout, I will do a blood test to measure the serum uric acid, however, this is not always a great test. Often the serum uric acid is normal even during an acute gout attack. When the uric acid blood test is normal you cannot exclude gout as your diagnosis, however, if the serum uric acid is high then you do have your diagnosis. Medically, we call this a false negative when the uric acid is normal but it really is gout. We also say that this blood test “can rule gout in but cannot rule out gout”.

The most accurate way to diagnose gout is to pull fluid out of the painful joint with a rather large needle. I rarely do this because it hurts a lot. Also, the great toe joint is a small joint with very little fluid and it is really hard to get any fluid out of it. When fluid is taken out of the joint, the pathologist looks under a microscope to see if there are uric acid crystals in it. Normally there are none so if he/she sees any, you definitely have gout.

Acute gout attack treatment:

The first line of treatment is anti-inflammatory medications.  The old anti-inflammatory medicine used is Colchicine. Personally, I rarely use colchicine but it is still an acceptable treatment method used today. The reason I don’t use colchicine is because it causes side effects. Patients are told to continue the colchicine until either they vomit or have diarrhea, whichever comes first. Both not very pleasant sequelae.

Instead of colchicine, I use Indomethacin (aka Indocin). Indomethacin is in the same class of drugs as aspirin or Motrin but is stronger. For unknown reasons it works better on gout attacks than other anti-inflammatory drugs in the same class. Other anti-inflammatory drugs work well too, but I find Indomethacin to work the best. I prescribe Indomethacin 50mg, one by mouth three times a day for the first 4-5 days, then twice a day for up to 7-8 days. It is taken with food. I tell patients to stop it when the pain subsides or they reach 7-8 days and then follow up.

When people cannot tolerate Indomethacin because of stomach problems, I usually prescribe Celebrex. Celebrex is in a class of anti-inflammatory drugs called Cox-2 inhibiters. These drugs have less adverse effects on the stomach.

Another treatment is steroid injection into the joint. I do this when the symptoms are really severe. The steroid injection is a very strong anti-inflammatory, placed exactly where the inflammation is. It works almost immediately usually to resolve the pain. Unfortunately, it hurts going in. I have to stick a needle into an already painful, inflamed joint.

Oral steroids also work well but have more side effects than the Indomethacin. Icing the painful area will help as well. Resting the effected joint with decrease pain too.

Long term treatment involves oral medications to prevent the build up of uric acid in the blood. Again, as a podiatrist, I will skip this as it exceeds the scope of my blog post. One thing I will write about this is, do not take these uric acid lowering medicines while in the acute stages of gout as they often make the gouty attack worse.

Below are pictures of the gouty tophus that I took out. This is the result of many years of build up of uric acid in and around a joint.

Thanks for reading and I hope I’ve helped. The subject of gout is huge and I could have written many times as much as this already long post…

Below are two pre-operative pictures of gout (click any picture to enlarge):

Below are intra-op pictures of the gouty tophus coming out:

And finally below is a picture of the gout tophus once it was removed from the foot:

And, lastly, below is a picture from a different surgery. This is a picture of uric acid crystals, gouty tophus, I encountered when doing bunion surgery. I did not expect to see this as they patient never had a history of any gout attacks, however, apparently, he had chronic gout and did not know it.

Lawrence