痛風石手術矯治. Orthopedic Surgery for Gout Tophi 振興復健醫學中心骨科部熊永萬

Transcription

1 痛風石手術矯治 Orthopedic Surgery for Gout Tophi 振興復健醫學中心骨科部熊永萬 Introduction: Tophus (from Latin for stone) is a deposit of crystallized uric acid normally found only under the skin. Commonly, they occur on fingers, toes and around the knees and ankles. Tophi are firm chalky, gritty clumps of uric acid crystals that build up in tissue surrounding a joint. If gout is not treated, tophi can grow to the size of golf balls and can destroy bone and cartilage in the joints, Small tophi are not always obvious, but appear as movable lumps. When they grow larger they can be seen as whitish nodules that can become painful, particularly if they are near joint to restrict movements. They usually occur around 10 years after the onset of gout, but can occur earlier, particularly for older people. The most common symptom & sign of gout in limbs are tenosynovitis, compressive neuropathies and asymmetrical joint swelling with articular degenerative changes. Tophi can be removed surgically. If they are infected (which is not common, but does occur), they would require drainage and antibiotics. Multiple tophi nodules in the ankle & foot ( The skin over the tophi lumps form ulcers and secrete pus. )

2 Multiple tophi nodules in the forearm & hand. Case Illustrations: A 49-year-old male complained of painful disability over left elbow for months. He has suffered from joint pain with hyperuricemia for years. Painful disability over left elbow due to tophi. Bone erosion over ulna olecranon.

3 S/P Removal of tophi over left forearm & hand. Compressive median nerve neuropathy due to tophi.

4 S/P Removal of tophi around median nerve with neurolysis. A 42-year-old male with diffuse intraosseous tophi located in both knees. Bilateral total knee arthroplasty was performed to improve knee function. Painful disability over both knees due to tophi in the joints.

5 Chronic inflammation and the presence of tophi in the joints accelerate joint degeneration, which lead to deformity and disability. Tophi erode cartilage and bone in the knee joint.

6 S/P Bilateral total knee arthroplasty. Free motion over both knees after bilateral knee arthroplasty.

7 A 65-year-old male with chronic hyperuricemia under medical treatment for years. He had a bizarre mass in right big toe. X-ray showed osteolysis over the big toe with joint destruction. Two stages of surgical intervention were done to restore big toe contour and function. Deformity and bony destruction with osteolysis over the big toe. Amputation of the big toe advised by clinic doctor.

8 Keeping the alignment of the big toe with pin after removal of tophi & drainage at the first stage.

9 Debridement & bone graft in the big toe at the second stage. Restoration of joint function & reconstruction of the joint deformity after orthopedic surgery.

10 Discussion: For most people, the first attack of gout occurs in the joint, resulting in excessive soreness, pain, swelling, heat and redness. Tophus is a strong indication that the condition of gout is serious that it has not been treated well so far. Chronic gout affects multiple joints all the time. In this stage, pain at multiple joints persists and large lumps of uric acid deposits are present. Treatment for gout should begin early to prevent long-term complications, such as chronic tophaceous gout, the formation of kidney stones and kidney damage. In secondary gout, treatment of the primary condition causing gout may control the disease. Chronic inflammation and the presence of tophi in the joints can accelerate joint degeneration, which can lead to deformity and disability. Gout can usually be successfully treated by eliminating causes and taking medications to relieve symptoms. However, if tophi are causing infection, pain, pressure, and deformed joints, and medications have been unsuccessful in shrinking and eliminating the tophi, surgery may be the only option. Conclusion: Tophi are generally painless. However, they can cause pain and stiffness in the affected joint. Eventually, they can also erode cartilage and bone, ultimately destroying the joint. Surgery is rarely needed for gout unless significant joint damage has occurred from lack of effective and timely treatment. Sometimes surgery may be performed to remove large tophi that are draining (oozing), infected or interfere with normal joint movement. In very severe cases, patients may have to undergo joint replacement surgery (arthroplasty.) Orthopedic surgery is indicated for restoration of joint function and reconstruction of joint deformity.