The Journal of Foot & Ankle Surgery xxx (2015) 1–3
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Case Reports and Series
Intraosseous Gouty Tophus at the Talus: A Case Report Chin-Horng Su, MD 1, Jui-Kuo Hung, MD 2 1 2
Senior Resident, Orthopaedic Department, ChangHua Christian Hospital, Changhua City, Taiwan Attending Physician, Orthopaedic Department, ChangHua Christian Hospital, Changhua City, Taiwan
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Isolated intraosseous gouty invasion is a rare presentation of gout. Although most patients will have a history of gouty arthritis or hyperuricemia, others will have an insidious onset of local pain, tenderness without significant swelling, or inflammation. Surgical debridement is the mainstay of treatment for intraosseous tophus formation. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: ankle arthritis gout hyperuricemia monosodium urate talar body
Gout is a chronic form of arthritis caused by excess levels of uric acid in the blood. Although the disease normally results in the deposition of monosodium urate crystals in the connective tissue, kidney, and skin, intraosseous deposition of monosodium urate can occur in the clavicle, femoral condyle, metatarsal bone, sesamoid bone, phalanges, patella, calcaneus, vertebral body, and talus (1–7). However, intraosseous gouty invasion of the foot or ankle area is very rare (7–9). We report the 15-month outcome of a patient with intraosseous gout at the talus that was treated by curettage and artificial bone grafting.
Magnetic resonance imaging of the right ankle showed an oval lesion with low signal intensity on the T1-weighted sequences and high signal intensity on the T2-weighted sequences (Fig. 2). The preliminary diagnosis was a benign, locally invasive bone tumor such as a giant cell tumor, and an open biopsy was performed. With the patient supine and under general anesthesia, a 5-cm skin incision was made along the posteromedial border of the
Case Report A 42-year-old male with a history of hypertension presented to a different clinic with a 6-month history of ambulation-induced left ankle pain. The patient denied a history of gout. The preliminary diagnosis was a talus bone tumor, and he was referred to our hospital for treatment. On arrival, the physical examination revealed mild local tenderness but no evidence of localized swelling, redness, or other local inflammation signs. In addition, no limitation in the right ankle range of motion and no evidence of tophus formation were found. Radiographs of the right ankle showed an osteolytic bony lesion in the talus measuring 20 mm 20 mm 25 mm, with peripheral sclerotic changes (Fig. 1) and periarticular soft tissue swelling at the ankle joint. Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Jui-Kuo Hung, MD, Orthopaedic Department, ChangHua Christian Hospital, 7F., No. 9, Ln. 72, 9 Nanxiao Street, Changhua City, Changhua County 10500 Taiwan, Republic of China. E-mail address: [email protected] (J.-K. Hung).
Fig. 1. Osteolytic lesion at the ankle. Radiographs of the right ankle revealed an osteolytic bony lesion on the talus measuring 20 mm 20 mm 25 mm with peripheral sclerotic changes.
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.09.001
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C.-H. Su, J.-K. Hung / The Journal of Foot & Ankle Surgery xxx (2015) 1–3
Fig. 2. Magnetic resonance imaging of the right ankle. (A) Low signal intensity on T1-weighted sequences and (B) high signal intensity on T2-weighted sequences.
posterolateral aspect of the left ankle. The subcutaneous tissues and muscles were split to expose the talus dome. During the approach, chalky white particles covering the synovium and soft tissue were noted. A cortical window was created, exposing a cystic mass filled with a whitish chalk-like material. Intraosseous gout was suspected. The mass was removed by curettage and the space filled with 10 mL of artificial bone. The bony window was covered with a gelatin sponge (Gelfoam,Ò Pfizer, New York, NY). Crystal analysis of the biopsy specimen confirmed the presence of monosodium urate. Histologic examination revealed crystalloid material surrounded by giant cells, indicating a foreign body reaction (Fig. 3). Range of motion exercises with protective weightbearing were started shortly after the operation. A blood workup revealed hyperuricemia (10 mg/dL). Oral colchicine was, therefore, prescribed. The patient was discharged without incident on postoperative day 4. The patient was able to achieve full weightbearing on the ankle without pain 4 weeks after surgery. At the 15-month follow-up, the patient reported no ankle pain, local swelling, or recent gout attack. In addition, radiographs taken at that time revealed no evidence of joint line collapse (Fig. 4).
Fig. 3. Histologic examination of the lesion. Hematoxylin-eosin stain (original magnification 400) shows crystalloid material surrounded by giant cells, indicating a foreign body reaction.
Discussion Intraosseous monosodium urate deposits are uncommon in patients with a history of gout. Monosodium urate tends to deposit in the metaphyseal and subchondral bones and usually presents as a pseudotumor or solid mass on imaging studies (2). Most patients with intraosseous lesions have a history of gout before the lesions are found (1). Patients often complain of pain when walking without local acute inflammatory symptoms or signs, such as redness, local heat, severe pain, or tenderness (1,2,6,9). The joint range of motion is rarely influenced if no intra-articular involvement is present (10). Although gout is a common disease, it is necessary to differentiate intraosseous cystic gout lesions from neoplasms or other pathologic conditions, such as enchondroma, unicameral cyst, chondroblastoma, chondromyxoid fibroma, osteochondritis dissecans, giant cell tumor, metastatic tumor, and infection. Plain film radiographs are normally used to establish a preliminary diagnosis, followed by computed tomography or magnetic resonance imaging for the differential diagnosis. To the best of our knowledge, the present case is the largest intraosseous gouty invasion of the foot or ankle area to be reported (2,3,6– 9). The radiographic findings in our patient are compatible with those in previous studies (i.e., punched out, round, or oval lesions with sclerotic rims) (1,2,5,7). In a review of the published data, a low signal intensity on both T1- and T2-weighted magnetic resonance images is characteristic of gouty tophus (11,12). In our patient, however, the lesion presented with low signal intensity on the T1-weighted images and high signal intensity on the T2-weighted images. Size can also help in the differentiation between tumor and cystic lesions. According to a study by Wright (12), any cyst >5 mm implies the existence of gout. Surgical treatment followed by medication has been the mainstay of treatment of gout. Intralesional curettage, followed by artificial bone grafting to fill the bone defect, was reported to be a successful treatment of intraosseous gout (7). The surgical pitfalls include cortical window creation, periosteum preservation, and removal of urate deposits. Artificial bone grafting to fill the bone defect has been suggested to avoid iatrogenic fracture, especially in weightbearing extremities. Other surgical methods include radical excision, arthroscopic debridement, and open biopsy, depending on the lesion site and size (1,3,4,6,7). In conclusion, intraosseous gouty lesions often appear as cystic lesions and can be the first manifestation of gout. A careful differential
C.-H. Su, J.-K. Hung / The Journal of Foot & Ankle Surgery xxx (2015) 1–3
3
Fig. 4. Postoperative radiographs showing a well-filled lesional space without intra-articular leakage on both (A) anteroposterior and (B) lateral views.
diagnosis and a detailed treatment plan are keys to effective treatment. References 1. Foucar E, Buckwalter J, El-Khoury GY. Gout presenting as a femoral cyst: a case report. J Bone Joint Surg Am 66:294–297, 1984. 2. Surprenant MS, Levy AI, Hanft JR. Intraosseous gout of the foot: an unusual case report. J Foot Ankle Surg 35:237–243, 1996. 3. Liu SZ, Yeh L, Chou YJ, Chen CK, Pan HB. Isolated intraosseous gout in hallux sesamoid mimicking a bone tumor in a teenaged patient. Skeletal Radiol 32:647– 650, 2003. €r I. Intraosseous tophaceous gout in the proximal phalanx of 4. Oti FE, Reichert B, Ba the small finger. J Hand Surg Eur Vol 37:696–697, 2012. http://dx.doi.org/10.1177/ 1753193412442290.
5. Melloni P, Valls R, Yuguero M, Larrosa M. Unusual imaging manifestations of intraosseous tophaceous gout of the patella. J Rheumatol 32:959–961, 2005. 6. Yun CH, Shih SL, Fang YK, Hung YC, Huang JK. Juvenile intraosseous gout of the calcaneus. Pediatr Radiol 35:899–901, 2005. 7. Morino T, Fujita M, Kariyama K, Yamakawa H, Ogata T, Yamamoto H. Intraosseous gouty tophus of the talus, treated by total curettage and calcium phosphate cement filling: a case report. Foot Ankle Int 28:126–128, 2007. 8. Ercin E, Gamsizkan, Avsar S. Intraosseous tophus deposits in the os trigonum. Orthopaedics 35:e120–e123, 2012. http://dx.doi.org/10.3928/01477447-20111122-32. 9. Raikin S, Cohn BT. Intraosseous gouty invasion of the talus. Foot Ankle Int 18:439– 442, 1997. 10. Chen CK, Yeh LR, Pan HB, Yang CF, Lu YC, Wang JS, Resnick D. Intra-articular gouty tophi of the knee: CT and MR imaging in 12 patients. Skeletal Radiol 28:75–80, 1999. 11. Gentili A. Advanced imaging of gout. Semin Musculoskeletal Radiol 7:165–174, 2003. 12. Wright J. Unusual manifestations of gout. Aust Radiol 10:365–374, 1966.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Case Reports and Series
Intraosseous Gouty Tophus at the Talus: A Case Report Chin-Horng Su, MD 1, Jui-Kuo Hung, MD 2 1 2
Senior Resident, Orthopaedic Department, ChangHua Christian Hospital, Changhua City, Taiwan Attending Physician, Orthopaedic Department, ChangHua Christian Hospital, Changhua City, Taiwan
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Isolated intraosseous gouty invasion is a rare presentation of gout. Although most patients will have a history of gouty arthritis or hyperuricemia, others will have an insidious onset of local pain, tenderness without significant swelling, or inflammation. Surgical debridement is the mainstay of treatment for intraosseous tophus formation. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: ankle arthritis gout hyperuricemia monosodium urate talar body
Gout is a chronic form of arthritis caused by excess levels of uric acid in the blood. Although the disease normally results in the deposition of monosodium urate crystals in the connective tissue, kidney, and skin, intraosseous deposition of monosodium urate can occur in the clavicle, femoral condyle, metatarsal bone, sesamoid bone, phalanges, patella, calcaneus, vertebral body, and talus (1–7). However, intraosseous gouty invasion of the foot or ankle area is very rare (7–9). We report the 15-month outcome of a patient with intraosseous gout at the talus that was treated by curettage and artificial bone grafting.
Magnetic resonance imaging of the right ankle showed an oval lesion with low signal intensity on the T1-weighted sequences and high signal intensity on the T2-weighted sequences (Fig. 2). The preliminary diagnosis was a benign, locally invasive bone tumor such as a giant cell tumor, and an open biopsy was performed. With the patient supine and under general anesthesia, a 5-cm skin incision was made along the posteromedial border of the
Case Report A 42-year-old male with a history of hypertension presented to a different clinic with a 6-month history of ambulation-induced left ankle pain. The patient denied a history of gout. The preliminary diagnosis was a talus bone tumor, and he was referred to our hospital for treatment. On arrival, the physical examination revealed mild local tenderness but no evidence of localized swelling, redness, or other local inflammation signs. In addition, no limitation in the right ankle range of motion and no evidence of tophus formation were found. Radiographs of the right ankle showed an osteolytic bony lesion in the talus measuring 20 mm 20 mm 25 mm, with peripheral sclerotic changes (Fig. 1) and periarticular soft tissue swelling at the ankle joint. Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Jui-Kuo Hung, MD, Orthopaedic Department, ChangHua Christian Hospital, 7F., No. 9, Ln. 72, 9 Nanxiao Street, Changhua City, Changhua County 10500 Taiwan, Republic of China. E-mail address: [email protected] (J.-K. Hung).
Fig. 1. Osteolytic lesion at the ankle. Radiographs of the right ankle revealed an osteolytic bony lesion on the talus measuring 20 mm 20 mm 25 mm with peripheral sclerotic changes.
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.09.001
2
C.-H. Su, J.-K. Hung / The Journal of Foot & Ankle Surgery xxx (2015) 1–3
Fig. 2. Magnetic resonance imaging of the right ankle. (A) Low signal intensity on T1-weighted sequences and (B) high signal intensity on T2-weighted sequences.
posterolateral aspect of the left ankle. The subcutaneous tissues and muscles were split to expose the talus dome. During the approach, chalky white particles covering the synovium and soft tissue were noted. A cortical window was created, exposing a cystic mass filled with a whitish chalk-like material. Intraosseous gout was suspected. The mass was removed by curettage and the space filled with 10 mL of artificial bone. The bony window was covered with a gelatin sponge (Gelfoam,Ò Pfizer, New York, NY). Crystal analysis of the biopsy specimen confirmed the presence of monosodium urate. Histologic examination revealed crystalloid material surrounded by giant cells, indicating a foreign body reaction (Fig. 3). Range of motion exercises with protective weightbearing were started shortly after the operation. A blood workup revealed hyperuricemia (10 mg/dL). Oral colchicine was, therefore, prescribed. The patient was discharged without incident on postoperative day 4. The patient was able to achieve full weightbearing on the ankle without pain 4 weeks after surgery. At the 15-month follow-up, the patient reported no ankle pain, local swelling, or recent gout attack. In addition, radiographs taken at that time revealed no evidence of joint line collapse (Fig. 4).
Fig. 3. Histologic examination of the lesion. Hematoxylin-eosin stain (original magnification 400) shows crystalloid material surrounded by giant cells, indicating a foreign body reaction.
Discussion Intraosseous monosodium urate deposits are uncommon in patients with a history of gout. Monosodium urate tends to deposit in the metaphyseal and subchondral bones and usually presents as a pseudotumor or solid mass on imaging studies (2). Most patients with intraosseous lesions have a history of gout before the lesions are found (1). Patients often complain of pain when walking without local acute inflammatory symptoms or signs, such as redness, local heat, severe pain, or tenderness (1,2,6,9). The joint range of motion is rarely influenced if no intra-articular involvement is present (10). Although gout is a common disease, it is necessary to differentiate intraosseous cystic gout lesions from neoplasms or other pathologic conditions, such as enchondroma, unicameral cyst, chondroblastoma, chondromyxoid fibroma, osteochondritis dissecans, giant cell tumor, metastatic tumor, and infection. Plain film radiographs are normally used to establish a preliminary diagnosis, followed by computed tomography or magnetic resonance imaging for the differential diagnosis. To the best of our knowledge, the present case is the largest intraosseous gouty invasion of the foot or ankle area to be reported (2,3,6– 9). The radiographic findings in our patient are compatible with those in previous studies (i.e., punched out, round, or oval lesions with sclerotic rims) (1,2,5,7). In a review of the published data, a low signal intensity on both T1- and T2-weighted magnetic resonance images is characteristic of gouty tophus (11,12). In our patient, however, the lesion presented with low signal intensity on the T1-weighted images and high signal intensity on the T2-weighted images. Size can also help in the differentiation between tumor and cystic lesions. According to a study by Wright (12), any cyst >5 mm implies the existence of gout. Surgical treatment followed by medication has been the mainstay of treatment of gout. Intralesional curettage, followed by artificial bone grafting to fill the bone defect, was reported to be a successful treatment of intraosseous gout (7). The surgical pitfalls include cortical window creation, periosteum preservation, and removal of urate deposits. Artificial bone grafting to fill the bone defect has been suggested to avoid iatrogenic fracture, especially in weightbearing extremities. Other surgical methods include radical excision, arthroscopic debridement, and open biopsy, depending on the lesion site and size (1,3,4,6,7). In conclusion, intraosseous gouty lesions often appear as cystic lesions and can be the first manifestation of gout. A careful differential
C.-H. Su, J.-K. Hung / The Journal of Foot & Ankle Surgery xxx (2015) 1–3
3
Fig. 4. Postoperative radiographs showing a well-filled lesional space without intra-articular leakage on both (A) anteroposterior and (B) lateral views.
diagnosis and a detailed treatment plan are keys to effective treatment. References 1. Foucar E, Buckwalter J, El-Khoury GY. Gout presenting as a femoral cyst: a case report. J Bone Joint Surg Am 66:294–297, 1984. 2. Surprenant MS, Levy AI, Hanft JR. Intraosseous gout of the foot: an unusual case report. J Foot Ankle Surg 35:237–243, 1996. 3. Liu SZ, Yeh L, Chou YJ, Chen CK, Pan HB. Isolated intraosseous gout in hallux sesamoid mimicking a bone tumor in a teenaged patient. Skeletal Radiol 32:647– 650, 2003. €r I. Intraosseous tophaceous gout in the proximal phalanx of 4. Oti FE, Reichert B, Ba the small finger. J Hand Surg Eur Vol 37:696–697, 2012. http://dx.doi.org/10.1177/ 1753193412442290.
5. Melloni P, Valls R, Yuguero M, Larrosa M. Unusual imaging manifestations of intraosseous tophaceous gout of the patella. J Rheumatol 32:959–961, 2005. 6. Yun CH, Shih SL, Fang YK, Hung YC, Huang JK. Juvenile intraosseous gout of the calcaneus. Pediatr Radiol 35:899–901, 2005. 7. Morino T, Fujita M, Kariyama K, Yamakawa H, Ogata T, Yamamoto H. Intraosseous gouty tophus of the talus, treated by total curettage and calcium phosphate cement filling: a case report. Foot Ankle Int 28:126–128, 2007. 8. Ercin E, Gamsizkan, Avsar S. Intraosseous tophus deposits in the os trigonum. Orthopaedics 35:e120–e123, 2012. http://dx.doi.org/10.3928/01477447-20111122-32. 9. Raikin S, Cohn BT. Intraosseous gouty invasion of the talus. Foot Ankle Int 18:439– 442, 1997. 10. Chen CK, Yeh LR, Pan HB, Yang CF, Lu YC, Wang JS, Resnick D. Intra-articular gouty tophi of the knee: CT and MR imaging in 12 patients. Skeletal Radiol 28:75–80, 1999. 11. Gentili A. Advanced imaging of gout. Semin Musculoskeletal Radiol 7:165–174, 2003. 12. Wright J. Unusual manifestations of gout. Aust Radiol 10:365–374, 1966.
![[Gouty tophus].](/assets/img/hold.png)
