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

2. 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

3. ~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

4. (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)

5. Crystal Formation In
Joint
Medicine Net

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

7. Acute Attack
WebMD

8. 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

9. 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

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

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

12. 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

13. 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

14. 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”

15. 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 )

16. 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

17. 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 mg
Lisinopril 20 mg Aspirin 81 mg
Atenolol 50mg Protonix 40mg
Norco mg Co Q mg
Indomethacin 75mg Niacin ER 500mg
Allergy: Allopurinol

18. 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

19. 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

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

21. 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

22. 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

23. 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: /7/18: 5.4
4/30/18: /18/18: 5.2
GOAL: Uric Acid <5
Alternative Meds Discussed: 1)Krystexxa 2)Increasing Uloric to 160mg

24. 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

25. 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!”)

26. 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

27. 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)

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

29. 2 weeks post start of care
CASE REVIEW
2 weeks post start of care
Resolved: 8 weeks post start of care

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

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

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

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

34. 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