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Total knee arthroplasty in a patient with subcutaneous and intra-articular tophaceous gout: a case report.

Gout is a common disease caused by deposits of monosodium urate crystals accumulating in joints and surrounding tissues. After years of acute intermittent disease, about 10% of patients develop tophaceous gout. This chronic form of the disease affects skeletal structures, such as the skin, tendons, ligaments, and joints, severely limiting their range of motion. (1) Surgery may be a viable option in some cases, but it is associated with a high rate of complications, such as delayed wound healing, sepsis, and discharging sinus. Furthermore, as surgical outcome is worse in lower limbs than in upper limbs, (2) knee replacement surgery should be reserved for selected cases only.

We report the first case of bilateral knee arthroplasty in a patient with both articular and subcutaneous tophaceous gout.

Case Report

An 80-year-old man was referred to our hospital with a long history of sudden onset pain, swelling, and limited flexion in both knees. The gout also affected the bilateral first metatarsophalangeal joints and all other joints on both hands, causing severe deformities.

Physical examination showed a varus deformity in both knees with multiple large subcutaneous masses in front of the patella, causing a smooth skin surface (Fig. 1). The range of motion was 20[degrees] to 100[degrees] for both knees, and the patient was unable to walk any distance without help.

Plain radiography showed decreased medial joint space and osteophytes affecting the patellofemoral joint. Dense soft tissue of several masses with abnormal calcification was seen in the anteropatellar subcutaneous tissue. CT scan revealed irregular and marginal calcification around the mass in the medial parapatellar joint space.

Due to the severe pain, the patient's limited range of movement, and the radiographic findings, total knee arthroplasty (TKA) was considered. Possible surgical complications were explained to the patient well in advance of the intervention. During surgery of the right knee, great care was taken not to injure the soft tissue because most tophi were anterior, and loss of substance in this region could jeopardize the surgery and thus the outcome. All tophaceous deposits were dissected, taking special care not to damage the skin. The deposits were easy to remove from the extensor mechanism, but they were well attached to the skin (Fig. 2).

After surgery, the surgical wound healed correctly, and the patient achieved a range of movement from 120[degrees] to full extension. One year after right knee surgery, a TKA was inserted in the left knee. The surgery and postoperative period again was uneventful, and results were similar to those for the right knee.


The incidence and prevalence of gout has increased over the last few decades. This increase can be explained by factors, such as greater alcohol use, changes in dietary habits, modern life style, obesity, metabolic syndrome, and wider use of drugs causing hyperuricemia. (3)


Tophaceous deposits in knee joints and other areas have occasionally been reported, but detailed clinical information is lacking. (4,5) Eighty percent of non-treated gout patients develop tophi or present radiological manifestations within 20 years. (6) Furthermore, the prevalence of tophi appears to be increasing. (7) As this condition limits a joint's range of movement and can severely affect walking ability, joint replacements for gout osteoarthritis will likely become a more frequent surgical procedure in future. (8)

Currently, TKA is a common operation for all types of arthritis. However, tophaceous gout causing arthritis of the knee and requiring TKA is rare, (9) and simultaneous subcutaneous and articular tophaceous gout arthritis is exceptionally rare. The present case is the first report of TKA with this form of gout arthritis.


The reason why surgeons avoid surgical intervention in these patients is the associated high rate of complications, including delayed wound healing and sepsis with discharging sinus, (2) both extremely serious situations in arthroplasty surgery. The literature has described the need for revision knee surgery due to gouty arthropathy, presenting with signs and symptoms of a septic arthroplasty. This stresses the importance of prompt diagnosis, by recognizing crystals in the joint as a source of a painful knee arthroplasty. (10)


Although it is uncommon, surgery of tophaceous knee may be a valid therapeutic option in patients with severe pain, limited knee motion, deformity, and walking difficulties, particularly when both knees are affected. Furthermore, the option of waiting for the tophi to disappear is not a viable alternative as this is unlikely, even after years of hypouricemic therapy. (11)


Since his knee surgery, the patient has needed surgery for ulcerations caused by the tophi in interphalangical joints of both hands. However, he has had no recurrence of tophi in either replaced knee (Figs. 3 and 4).

In conclusion, this case report shows that total knee arthroplasty in patients with simultaneous subcutaneous and articular tophaceous knee may be a valid option with no significant complications. Notwithstanding, possible serious complications must be clearly explained to the patient well before surgery.

Disclosure Statement

None of the authors have a financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.

Caption: Figure 1 Preoperative right knee with subcutaneous multiple tophi masses erupting through the skin.

Caption: Figure 2 Intraoperative photograph of right knee when the chalky lumps were surgically removed.

Caption: Figure 3 Intraoperative photograph of right knee shows severe articular surfaces destruction covered with chalky deposit of sodium urate.

Caption: Figure 4 The photograph shows the bilateral knee replaced and severe inflammatory tophi affecting all fingers on the proximal and distal interphalangeal joints.


(1.) Larmon WA, Kutz JF. The surgical management of chronic tophaceous gout. J Bone Joint Surg Am. 1958 Jul; 40A(4):743-72.

(2.) Kumar S, Gow P. A survey of indications, results and complications of surgery for tophaceous gout. N Z Med J. 2002 Jul 26; 115(1158):U109.

(3.) Smith EU, Diaz-Torne C, Perez-Ruiz F, March LM. Epidemiology of gout: an update. Best Pract Res Clin Rheumatol. 2010 Dec; 24(6):811-27.

(4.) Gerster JC, Landry M, Dufresne L, Meuwly JY. Imaging of tophaceous gout: computed tomography provides specific images compared with magnetic resonance imaging and ultrasonography. Ann Rheum Dis. 2002 Jan; 61(1):52-4.

(5.) Chen SY, Chen CL, Shen ML, Kamatani N. Trends in the manifestations of gout in Taiwan. Rheumatology (Oxford). 2003 Dec; 42(12):1529-33.

(6.) Yu TF, Gutman AB. Principles of current management of primary gout. Am J Med Sci. 1967 Dec; 254(6):893-907.

(7.) Chen CK, Chung CB, Yeh L, et al. Carpal tunnel syndrome caused by tophaceous gout: CT and MR imaging features in 20 patients. AJR Am J Roentgenol. 2000 Sept; 175(3):665-9.

(8.) Yu KH, Lien LC, Ho HH. Limited knee joint range of motion due to invisible gouty tophi. Rheumatology. 2004 Feb; 43(2):191-4. Epub 2003 Aug 29.

(9.) Sekiya H, Takatoku K, Kojima R, Hoshino Y. Tophaceous knee arthritis requiring total knee arthroplasty. Current Orthop Practice. 2010 Dec-Nov; 21(6):42-4.

(10.) Freehill MT, McCarthy EF, Khanuja HS. Total knee arthroplasty failure and gouty arthropathy. J Arthroplasty. 2010 Jun; 25(4):658.e7-10.

(11.) Falasca GF. Metabolic diseases: gout. Clin Dermatol. 2006 Nov-Dec; 24(6):498-508.

Xavier Aguilera, M.D., Jose Carlos Gonzalez, M.D., Fernando Celaya, M.D., Ph.D., and Marcos Jordan, M.D., are in the Orthopaedic Surgery of the Knee Unit; Cesar Diaz-Torne, M.D., is a Consultant in Rheumatology; and Joan Carles Monllau, M.D., Ph.D., is a Consultant in Orthopaedic Surgery; at the Hospital de la Santa Creu i Sant Pau, Universitat Autonoma, Barcelona, Spain. Correspondence: Xavier Aguilera, M.D., Department of Orthopedics and Traumatology, Hospital de la Santa Creu i Sant Pau, C/ Sant Antoni M1 Claret 167, 08025- Barcelona, Spain; xaguilera@
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Author:Aguilera, Xavier; Gonzalez, Jose Carlos; Celaya, Fernando; Jordan, Marcos; Diaz-Torne, Cesar; Monlla
Publication:Bulletin of the NYU Hospital for Joint Diseases
Article Type:Clinical report
Date:Apr 1, 2014
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