GOUT AND PSEUDOGOUT

What is gout?

Gout was first described in the 4th century by Hippocrates.  Gout affects approximately 1% of the British population, mostly men over 40.
There is an excess of a normal body chemical, called “urate” in the blood and tissues.  After a time, crystals of urate form in and around joints.  When urate crystals enter the joint, they cause inflammation.
Most patients have increased urate because the chemical is not passed into the urine efficiently enough.  Gout can also be precipitated by high levels of uric acid in the diet (the classic red wine link), or by drugs eg. Diuretics (“water tablets”) or chemotherapy.
Primary gout is most likely to occur in men between 40 and 60.  Acute attacks are common, and this proceeds to chronic gout if untreated.
Secondary gout is usually related to diuretic drugs, and is correspondingly seen in an older age-group, in both men and women.  Acute attacks are less frequently seen.

Making the diagnosis

The Hand specialist who sees the patient will ask questions about their symptoms, when they started, how they progressed, what treatment (if any) they have had and other questions relevant to the problems. They will then examine the patient. Stressing i.e. pushing on the affected joint is usually uncomfortable. It is necessary to demonstrate some tenderness to confirm the site of the symptoms but this should not be too painful. The specialist may measure the range of motion in the joint with a special angular ruler (goniometer). This will help guide their advice to the patient.
A single joint is most commonly affected in an acute attack.  The joint at the base of the big toe is affected in half of first attacks.  Other common sites are the small joints of the hand, wrist, elbow, foot, ankle and knee.  The pain develops over a few hours, often overnight.  There may be a fever.  There is intense pain in the affected joint, with redness, swelling and extreme tenderness; even bedclothes touching cannot be tolerated. 
Tophi are large crystal deposits, frequently seen in the cartilage of the ear, and extensor surfaces of the fingers, elbows and feet.  They are seen in chronic gout.

What test(s) might be performed?

Tests include a blood urate level, however this may actually be lowered during an acute attack, and should therefore be measured between attacks.
Definitive diagnosis rests upon finding urate crystals within a sample of joint fluid.
An XRay of the affected joint  is initially normal, but may show erosions after repeated attacks.  As destruction proceeds, there may be secondary osteoarthritis.

Treatment:

What are the non-operative treatments?
Treatment of the acute attack involves pain relief with anti-inflammatories.  Attempting to lower the urate level may actually prolong the attack, and is avoided.  An alternative drug called Colchicine is sometimes useful for patients who cannot take anti-inflammatories. 
Reduction of risk factors (weight loss, alcohol avoidance and stopping diuretic therapy) are important in reducing further attacks.
A preventative drug called Allopurinol is used for patients with recurrent attacks, or joint damage.

What are the surgical options?
Joints badly damaged by gout can sometimes be helped by fusing in a comfortable and useful position.  This is not very often necessary.
The calcific deposits may be excised (surgically removed) if they ulcerate or cause other problems.

What is Pseudogout?

Pseudogout affects the elderly, both men and women.
Acute gout is very similar to pseudogout, and they may co-exist.  However, pseudogout is more likely to affect the knee, wrist, shoulder or ankle.  It is the most common cause of acute arthritis in the elderly.  There is usually no provoking cause, but it may occur after general illness or minor trauma.  The crystals in the joint fluid are of calcium pyrophosphate, rather than urate.
The XRay in pseudogout may show osteoarthritis, and calcium within the cartilages, especially of the knee, the wrist, or the pelvis. 

Treatment:

What are the non-operative treatments?
Treatment of the acute attack involves pain relief with anti-inflammatories.  Sometimes removal of the joint fluid helps pain and aids the diagnosis.  The joint may be splinted in a comfortable position with a plaster cast or plastic splint to help pain relief.
What are the surgical options?
Very occasionally the acutely arthritic joint with pseudogout will not settle without having the joint fluid washed away.  This is done with key-hole surgery “arthroscopy”.  Joints badly damaged by pseudogout can sometimes be helped by joint replacement “arthroplasty” or fusion “arthrodesis” in a comfortable and useful position.  This is very rarely necessary.

 
 

The Hand to Elbow Clinic
29a James Street West
Bath BA1 2BT

Tel 01225 316895
Fax 01225 484949
info@handtoelbow.com
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