Tophaceous Gout and Wound Healing Sue Collins PT CWS May 10, 2019

Gout Overview Most common type of inflammatory arthropathy Affects > 8 million Americans (~4% of adult population) 10 x more common in men than women until menopause Average onset in men: ages 30-50 Worldwide problem Prevalence is increasing

~High concentration of purines~ Risk Factors Obesity PMH: HTN, Hyperlipidemia, DM, heart and kidney disease Genetic component Diet: Red and organ meats, seafood, sweetened beverages, ETOH (esp. beer) ~High concentration of purines~ Certain meds: Thiazide diuretics

(commonly in great toe: 1st MTP joint) Development of Gout Characterized by hyperuricemia: uric acid levels exceed 6.8 mg/dL Uric acid produced during digestion: breakdown of purines Uric acid is excreted by kidneys Gout: result of excess production or ineffective excretion Elevated acid in system causes urate crystal formation: lodges in joints ↓ Leads to “gout attack”: sudden severe pain and inflammation (commonly in great toe: 1st MTP joint)

Crystal Formation In Joint Medicine Net

Progression of Gout Acute attacks last from few days/few weeks Initially monoarticular: resolves rapidly with tx (asymptomatic in between) Recurrence rate varies

Acute Attack WebMD

Early Medical Management is Key Progression of Gout Without treatment →Chronic disease Multiple joint involvement (toes, ankles, fingers, wrists, knees, elbows) More frequent attacks Chronic pain Permanent joint damage and loss of mobility Development of tophi→ tophaceous periarticular gout Early Medical Management is Key

Tophi Formation Tophi: small collections of monosodium urate crystals form in joint’s cartilage or bones Visible nodule, continues to grow in size if untreated Medication management → growth halted, tophi dissolve Common location: Feet/Hands Multiple joints and soft tissues over time Usually not painful except during attacks

Tophi Occurs after 10 years or more of untreated periarticular gout Medical News Today

Tophaceous Gout and Wounds May progress to skin breakdown Uncommon Often at weight bearing areas Difficult to treat WebMD

Include pain relievers, anti-inflammatory and antihyperuricemic agents GOUT MANAGEMENT Control of hyperuricemia is crucial Medications: individualized: used for prevention, treatment and reduction of complication risks Include pain relievers, anti-inflammatory and antihyperuricemic agents Lifestyle changes weight loss, smoking cessation, ↓intake of purine rich foods behavioral changes: rarely effective on own Surgery: advanced cases: joint involvement, tophi excision Advanced wound care: ulcerations are rare and challenging

CASE REVIEW 55 y/o male PMH: HTN, Hyperlipidemia GERD, Morbid Obesity, Gout Gout onset: “teen years” Long Hx of poorly controlled polyarticular tophaceous gout 6’ tall 338 pounds (BMI 45.8) Family Hx: Gout (father/brother) Social Hx: Married/Children Occupation: Mining Engineer (extensive travel) Never Smoker Alcohol: Rare

CASE REVIEW No Rheumatology F/U Lifetime history of “small” gout attacks Controlled with diet and indomethacin prn Reported triggers: red wine, shellfish, and “going to Vegas”

CASE REVIEW Initial Ortho consult: Foot/Ankle Specialist: 10/5/17 Severe tophaceous deposits bilateral 1st MTP joints: left > right Large soft tissue mass on left lateral midfoot Subjective: Patient c/o left foot pain 9/10 Difficulty finding shoes that fit/ limited tolerance to steel toe shoes Diagnostic tests: Xray: Left foot: Significant periarticular erosion into 50% of 1st MT head MRI: Erosive changes of left 1st MT head and proximal phalanx, 2nd MT head and slightly into 3rd and 4th MT, marginal erosion at TMT joints, gouty tophus on lateral foot Labs: Uric Acid: 9.7 H (normal range 3.5-8.5)

CASE REVIEW Surgery: 1/24/18: Outpatient Excision of tophaceous deposit: Left 1st MT Excision of soft tissue tophaceous mass left midfoot Fusion of 1st MTP Post Op Management: Initially NWB/knee walker, leg elevation, ace wraps, pain meds CAM boot→PWB→WBAT (modified post op shoe) 6 months off work Wound dehiscence at 1st MT noted 3/12/18→Referred to WCC, IV abx: Augmentin

CASE REVIEW Initial AGH WCC evaluation: 4/10/18 (after 1 month tx at outside WCC) Presented with joint pain left foot + swelling+ open wound Ambulatory with crutches/CAM boot MEDICATIONS Crestor 10mg Augmentin 875-125mg Lisinopril 20 mg Aspirin 81 mg Atenolol 50mg Protonix 40mg Norco 10-325mg Co Q10 100mg Indomethacin 75mg Niacin ER 500mg Allergy: Allopurinol

CASE REVIEW Multiple Tophi: Feet and Hands Wound Dimensions: Left 1st MT incision: 1.0x1.0x1.5cm Exudate: Moderate: Serosanguinous Gout: Uric acid is elevated in exudate/higher concentrations correlate with increased wound severity Wound Base: Partially granular with white gouty material in base Periwound: Erythematous

CASE REVIEW Pain: 7/10 (with weight bearing) Mild-moderate edema: left foot and ankle DP Pulses: intact bilaterally Wound Cultures: Aerobic/Anaerobic: Rare Staph, Rare Gram+ Cocci, Ø WBC seen

INITIAL WOUND CENTER VISIT April 10, 2018 CASE REVIEW INITIAL WOUND CENTER VISIT April 10, 2018

CASE REVIEW Tx: 1) .25% Dakin’s solution/NuGauze/Daily (wife instructed) 2) Tubular Compression Sleeve 3) Continue CAM boot+ AD 4) Weekly WCC F/U Referral: 1) Rheumatology ASAP secondary to severity of disease 2) Eventual Pedorthist: Footwear Assessment

CASE REVIEW Rapid Rheumatology Intervention: 4/11/18 Consult Tophi: right 1st MTP, bilateral 3rd MCP, left 2nd PIP, left elbow Reduced ROM bilateral wrists, flexion contractures bilateral elbows Rx: Febuxostat (Uloric) 40mg QD (limits production of uric acid) Continue Indomethacin for flares Avoid steroids (wounds) Norco

CASE REVIEW Continued Rheumatology F/U Labs monitored Uloric dosage increased 40mg (April 2018)→80mg (May 2018)→120mg (September2018) Uric Acid Levels 10/20/17: 9.7 9/7/18: 5.4 4/30/18: 6.5 12/18/18: 5.2 GOAL: Uric Acid <5 Alternative Meds Discussed: 1)Krystexxa 2)Increasing Uloric to 160mg

CASE REVIEW Wound Care Progress POC evolved Initial Visit: 4/10/18 Discharged:4/2/19 (wound resolved) Weekly→Every 2 weeks Dressings: Dakin’s solution→ORC Collagen→Silver Mesh→Foam Hypergranulation: Silver nitrate, Sodium chloride impregnated gauze Sharp Debridement: Slough and crystalline gouty material

CASE REVIEW Advanced Technologies: disposable negative pressure unit, low frequency non-contact US CTP: Cryopreserved human skin allograft x 2 Compression: 2 layer compression wrap→tubular sleeve→none Wound site pressure relief: CAM→Modified Post Op shoe (cut out)→ Pedorthist provided shoe with inserts (“best shoes in years!”)

CASE REVIEW Importance of Footwear/Offloading: No advanced treatment or medical management can mitigate trauma from footwear 2 episodes of regression during course of care Healed/Reopened x 2 CT scan ruled out underlying pathology/structural issues Linked to footwear

Impact of Medical Management/Rheumatology CASE REVIEW Impact of Medical Management/Rheumatology Significant Wound healing accelerated Tophi Resorption Pain reduction Functional Improvement (back to work, comfortable shoes, no longer considering retirement, overall improved quality of life)

INITIAL EVALUATION APRIL 10, 2018 CASE REVIEW INITIAL EVALUATION APRIL 10, 2018

2 weeks post start of care CASE REVIEW 2 weeks post start of care Resolved: 8 weeks post start of care

(advanced modalities) CASE REVIEW Reopened (6 weeks post closure & back to work) Resolved (advanced modalities)

(CTP application planned) (acquired new shoes/pedorthist) CASE REVIEW Reopened (CTP application planned) Resolved (acquired new shoes/pedorthist)

CASE REVIEW One Year Post Initial Visit Remains resolved Last visit to WCC Return PRN Fingers Crossed

Motivated and Adherant Patient OUR SUCCESS Rheumatology Orthopedics Advanced Wound Care Pedorthics Supportive Family Motivated and Adherant Patient

Summary Development of chronic ulcers associated with tophaceous gout is uncommon: clinically challenging: no established guidelines for tx Team approach needed Treatment of underlying disease is critical More controlled studies needed to determine most effective approach and to identify risk factors and preventative strategies