Arthroscopic Elimination of Monosodium Urate Deposition of the First Metatarsophalangeal Joint Reduces the Recurrence of Gout

doi:10.1016/j.arthro.2008.09.002

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 25, Issue 2, February 2009, Pages 153-158

https://doi.org/10.1016/j.arthro.2008.09.002 Get rights and content

Purpose

To determine if the arthroscopic removal of gouty crystal deposits from the first metatarsophalangeal (MTP) joint will reduce the recurrence rate and improve foot function compared to medical treatment alone.

Methods

Twenty-eight male patients with hyperuricemia (>7.0 mg/dL) and repeated attacks of gouty arthritis of the first MTP joint were included in this study. Arthroscopic intervention of the first MTP joint was performed on 15 patients (group 1), while the other 13 patients were treated with medication alone (group 2). The follow-up period (mean ± standard deviation) was 3.9 ± 1.1 years in group 1 and 2.4 ± 0.3 years in group 2.

Results

After treatment, both groups showed a significant improvement in the number of acute attacks of gouty arthritis and in their functional scores on the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale. On both measures, the results for group 1 were significantly better than those for group 2.

Conclusions

Arthroscopic removal of gouty crystals from the first MTP joint can reduce the rate of acute repeated attacks of gouty arthritis and increase foot and ankle function.

Level of Evidence

Level IV, therapeutic case series.

Section snippets

Methods

Twenty-eight male patients with persistent hyperuricemia (>7.0 mg/dL) and repeated attacks of gouty arthritis of the first MTP joint were enrolled in the study. Fifteen patients (group 1) whose symptoms were not relieved by medical gouty therapy after 6 months were selected to undergo arthroscopic intervention (Table 1). The other 13 male patients (group 2) declined operative intervention but continued on anti-gout therapy² (Table 2). The exclusion criteria for the surgery group were acute

Results

The mean uric acid level decreased significantly in group 1 (9.66 ± 1.37 mg/dL v 6.61 ± 1.50 mg/dL; P < .001) and in group 2 (9.70 ± 1.73 mg/dL v 7.96 ± 1.16 mg/dL; P < .001). The mean number of acute attacks of gouty arthritis decreased significantly after treatment in group 1 (5.60 ± 1.40 v 0.20 ± 0.41; P = .001) and in group 2 (6.23 ± 1.48 v 4.31 ± 1.37; P = .001). The mean AOFAS Ankle-Hindfoot Scale score increased significantly in group 1 (68.80 ± 3.55 v 89.67 ± 2.28; P = .001) and in

Discussion

The indications for arthroscopy of the first MTP joint are the removal of dorsally located endophytes, dorsal impingement syndrome, arthroscopic treatment of osteochondritis dissecans, arthroscopic drainage for bacterial arthritis, removal of a painful sesamoid bone, and arthroscopic treatment of pigmented villonodular synovitis.4, 5, 6, 7 Arthroscopic treatment of osteochondritis dissecans has been shown to yield good results in joints such as the knee and the ankle.⁸ Ferkel and Van Buecken⁹

Conclusions

The arthroscopic removal of gouty crystals from the first MTP joint can reduce the rate of acute, repeated attacks of gouty arthritis and increase both foot and ankle function.

Acknowledgment

The authors thank Meei-Shyuan Lee, M.D., Associate Professor of the School of Public Health, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, for processing the statistical analysis.

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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.
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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.
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Several techniques and approaches for first metatarsophalangeal (MTP1) joint arthroscopy have been reported, where joint accessibility plays a key role. This study aimed to evaluate differences in arthroscopic accessibility of the first metatarsal head (MTH1) comparing non-invasive distraction and maximum plantarflexion in a two-portal approach.
Forty fresh-frozen lower leg specimens were included and divided into a distraction group (D-group) and a plantarflexion group (PF-group). A two-portal technique (1.9 mm-30°-scope) was used for arthroscopy, maximum reach at the MTH1 was marked. Following arthroscopy, specimens were dissected and examined for iatrogenic injuries. The reached area at the chondral surface was pinned and accessibility calculated.
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Gouty Involvement of Foot and Ankle: Beyond Flares
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Citation Excerpt :
In addition, a Cochrane review concluded more randomized-controlled trial data for surgical interventions of tophi is needed before drawing firm conclusions.54 One paper assessed the arthroscopic removal of MSU crystals from 1st MTP joints, comparing outcomes against “anti-gout therapy” in 28 patients.55 After more than two years, functional scores and number of attacks significantly favored the surgical group; furthermore, the final SU levels were also lower.
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.
El pie y el tobillo son lugares comunes de depósito de cristales de urato monosódico (UMS), como indican las manifestaciones clínicas que presentan los pacientes con gota, que no se limitan a la inflamación aguda del primer dedo del pie. Presentamos una revisión narrativa de la literatura con el objetivo de actualizar la implicación de la gota en pie y tobillo y cómo afecta a la calidad de vida. En la literatura se describe que la gota, incluso en la etapa no tofácea, podría causar dolor, deterioro de la marcha y limitaciones de la movilidad en las extremidades inferiores. Estos pacientes pueden presentar dificultades en algunas actividades de la vida diaria, como la elección de calzado, lo cual implica una calidad de vida deteriorada. La gota es una enfermedad curable si se disuelven los cristales de UMS, pero resulta incierto cómo esto podría modificar algunas de estas manifestaciones en pie y el tobillo, especialmente cuando el daño estructural ya ha ocurrido. Además, una colaboración entre reumatólogos y podólogos sería de utilidad para comprender y aliviar estos síntomas así como mejorar la calidad de vida de los pacientes con gota.
Rheumatic Diseases
2020, Neale’s Disorders of the Foot and Ankle

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Original ArticleArthroscopic Elimination of Monosodium Urate Deposition of the First Metatarsophalangeal Joint Reduces the Recurrence of Gout

Purpose

Methods

Results

Conclusions

Level of Evidence

Section snippets

Methods

Results

Discussion

Conclusions

Acknowledgment

Arthroscopy

Arthroscopy

The soft-tissue shaving procedure for deformity management of chronic tophaceous gout

Ann Plast Surg

The management of gout

N Engl J Med

Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes

Foot Ankle Int

Arthroscopic surgery of the metatarsophalangeal first joint

Arthrosocopy

Pigmented villonodular synovitis in the first metatarsophalangeal joint: arthroscopic treatment of an unusual condition

Foot Ankle Int

Arthrosocpy of the first metatarsophalangeal joint

J Bone Joint Surg Br

Original Article
Arthroscopic Elimination of Monosodium Urate Deposition of the First Metatarsophalangeal Joint Reduces the Recurrence of Gout