Case Report
Gout Arthropathy Following Hip Arthroplasty: A Need for Routine Aspiration Microscopy? A Review of the Literature and Case Report
Geriatric Orthopaedic Surgery & Rehabilitation 1(1) 36-37 ª The Author(s) 2010 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/2151458510373745 http://gos.sagepub.com
James Hahnel, FRCS1, Rajesh Ramaswamy, MSc, FRCS1, Andrew Grainger, FRCR1, and Martin Stone, FRCS1
Abstract This article presents the case of a patient with pain associated with a total hip replacement. Following aspiration microscopy, a diagnosis of gout in a total hip replacement was made. Successful treatment was instituted with medical management in the presence of coexisting aseptic loosening. Gout in a total hip replacement is an exceptionally rare diagnosis. The gold standard for diagnosis is not urate level but crystal identification in the synovial fluid. The authors would therefore recommend that as part of a thorough workup for painful prosthetic joint requiring revision, a present or past history of gout is sought and a fluid aspirate should be examined not only for infection but also under polarized light for crystal arthropathy. Keywords gout arthropathy, revision hip, aspiration microscopy
Gout arthropathy in a hip replacement is an extremely rare diagnosis. Gout typically presents with recurrent pain, erythema, and effusion of the large toe or knee. Diagnosis is made on clinical grounds and confirmed with elevated serum urate levels and/or the presence of monosodium urate crystals on microscopy of synovial fluid. A chronic painful prosthetic joint in the presence of radiographic loosening usually indicates aseptic loosening. This requires major revision surgery and all its accompanying potential complications to alleviate pain. This is often a major life-changing event in the frail elderly population. A 76-year-old woman with developmental dysplasia of bilateral hips underwent staged bilateral Charnley cemented total hip replacements at the age of 50 years. The right hip has remained mostly pain free for the past 25 years. The patient complained of intermittent right groin pain for the previous 6 years but more recently severe pain. On review of the right hip, radiographs showed signs of slowly progressive radiolucent lines over this same time period. These included DeLee and Charnley zones 1 to 3 and Gruen zone 1. The fast but intermittent clinical progression of pain contrasted with the slow and progressive radiographic appearance. A fluoroscopic-guided aspiration was arranged to exclude infection. Monosodium urate crystals were seen under polarized light, confirming the diagnosis of gout. No organisms were seen, and cultures grew no organisms either. Medical treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) was 36
instituted, and follow-up revealed complete resolution of symptoms. Within 2 months, the patient developed right groin pain once again with corresponding erythema and pain in her left hallux. Urate at this time was 237 umol/L (reference range, 140-380 umol/L), but medical management was instituted, again with resolution of symptoms. Direct questioning revealed previous symptoms consistent with gout in her hallux. Given the intermittent nature of the pain and medium-term resolution with short courses of NSAIDs, it appears possible that her exacerbations of pain have mainly related to gout with the background of aseptic loosening. The decision to revise this hip has currently been cancelled pending review. Her symptoms have completely resolved following medical treatment.
Discussion Gout is a spectrum of disorders relating to a defect in the metabolism of purine. It is manifest by crystalline deposits of 1
Orthopaedic Department, Leeds Teaching Hospitals Trust, Chapel Allerton Hospital, Chapeltown Road, Leeds, United Kingdom Corresponding Author: James Hahnel, The Firs, Arthington Lane, Pool in Wharfedale, Otley LS21 1JZ, England Email:
[email protected]
Hahnel et al monosodium urate (tophi), recurrent acute arthritis, and hyperuricemia. The prevalence of gout in England has been reported as approximately 1%,1 and in the 75- to 84-year-old age bracket in the United Kingdom, the prevalence is 4.5%.2 There have previously been only 2 cases reported of gout in a prosthetic hip.3,4 Gout in a total knee replacement has been described.5-7 This case demonstrates the effectiveness of thorough investigation prior to treatment. Without aspirating the joint looking for evidence of infection, we would not have been able to secure the diagnosis of gout and undoubtedly would have exposed our patient to needless risk of major revision surgery. It is apparent that the diagnosis of aseptic loosening is present. However, it is also long standing and slowly progressive. The patient’s pain appears to coincide with acute attacks of gout and is controlled by its medical management. In these conditions, early revision surgery should, in our opinion, be avoided. Direct questioning revealed a history of goutlike symptoms, demonstrating that history is vital to establishing a suspicion of alternative causes of hip pain. Archibeck et al8 suggested that patients with asymptomatic hyperuricemia, hemolytic anemias, renal insufficiency, myeloproliferative disorders, recent treatment of a malignancy, or diuretic therapy are at increased risk of developing hyperuricemia and gout. Healey et al3 rightly informs us of a need to see negatively birefringent crystals under polarized light to confirm the presence of monosodium crystals and exclude amorphous debris of polyethylene and polymethylmethacrylate. Ortman and Pack4 suggest that the aseptic loosening of their patient was secondary to deposition of gouty tophi. Archibeck et al8 reported at the planned first stage of a 2-stage revision for presumed infection total knee replacement, chalky deposits were noted. This was similar to the contralateral knee which had already been subject to a 2-stage revision knee replacement without identification of organisms. Therefore, an intraoperative decision was made to replace the polyethylene insert and perform a synovectomy. The patient was then successfully medically managed for gout. Similar chalky deposits have been noted at arthrotomy.4,9 With a preoperative aspirate analysis, an arthrotomy could have been avoided in these cases. Subsequent follow-up of our patient at 2 and 6 months revealed recurrence of right hip and hallux pain. Uric acid levels were noted to be normal. However, the prevalence of patients with acute gout with normal uric acid levels at diagnosis was found to be 12% by Park et al.10 In their review of diagnostic criteria for gout, Malik et al11 concluded that crystal identification in the synovial fluid remains the gold standard for identification of gout. In the elderly frail population, it is not always appropriate to subject patients to major revision procedures in the presence of
37 slowly progressive loosening. As can be seen, the coexistence of gout is possible to treat successfully. We would therefore recommend that as part of a thorough workup for painful prosthetic joint requiring revision, a present or past history of gout is sought and a fluid aspirate should be examined in all patients, not only for infection but also under polarized light for crystal arthropathy. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the authorship and/or publication of this article.
Funding The authors received no financial support for the research and/or authorship of this article.
References 1. Harris CM, Lloyd DC, Lewis J. The prevalence and prophylaxis of gout in England. J Clin Epidemiol. 1995;48:1153-1158. 2. Mikuls TR, Farrar JT, Bilker WB, Fernandes S, Schumacher HR Jr, Saag KG. Gout epidemiology: results from the UK General Practice Research Database, 1990-1999. Ann Rheum Dis. 2005; 64:267-272. 3. Healey JH, Dines D, Hershon S. Painful synovitis secondary to gout in the area of a prosthetic hip joint: a case report. J Bone Joint Surg Am. 1984;66:610-611. 4. Ortman BL, Pack LL. Aseptic loosening of a total hip prosthesis secondary to tophaceous gout: a case report. J Bone Joint Surg Am. 1987;69:1096-1099. 5. Freehill MT, McCarthy EF, Khanuja HS. Total knee arthroplasty failure and gouty arthropathy. J Arthroplasty. 2010;25(4):e7-e10. 6. Crawford L, Kumar A, Shepard GJ. Gouty synovitis after total knee arthroplasty: a case report. J Orthop Surg. 2007;15:384-385. 7. Blyth P, Pai VS. Recurrence of gout after total knee arthroplasty. J Arthroplasty. 1999;14:380-382. 8. Archibeck MJ, Rosenburg AG, Sheinkop MB, et al. Gout-induced arthropathy after total knee arthroplasty: a report of 2 cases. Clin Orthop Relat Res. 2001;392:377-382. 9. Williamson SC, Roger DJ, Petrera P, et al. Acute gouty arthropathy after total knee arthroplasty: a case report. J Bone Joint Surg Am. 1994;76:126-128. 10. Park YB, Park YS, Lee SC, et al. Clinical analysis of gouty patients with normouricaemia at diagnosis. Ann Rheum Dis. 2003;62(1):90-92. 11. Malik A, Schumacher HR, Dinnela JE, et al. Clinical diagnostic criteria for gout: comparison with the gold standard of synovial fluid crystal analysis. J Clin Rheum. 2009;15:22-24.
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