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I had a joint replacement on my big toe joint– why do I still have gout?

Is it possible to have gout following a joint replacement?

Gouty arthritis is a significant contributing factor to degenerative change in joints, leading to joint pain and often the need for jointGout replacement.  Gout is a common crystal induced form of arthritis that creates significant degenerative change in the joint.  The frequency and duration of gout attacks is  directly proportional to the rate of onset and severity of joint failure.

Gout attacks are caused by the accumulation of uric acid in the blood.  Uric acid combines with sodium to form monosodium urate.  Monosodium urate is the end metabolite of purine, a common organic compound found in our diets.  Monsodium urate is soluble in the blood at body temperature (37 degree Celsius)  but precipitates our of the blood as a crystal at 35 degrees Celsius. (1,2,3)  The great toe joint is the most common site of gout attacks for several reasons, most importantly it’s potential to be affected by external environmental temperatures.  That explains why the classic clinical onset of gout is in the middle of the night.

There are a host of local factors that may also contribute to the onset of a gout attack.  Those local factors include pH, mechanical stress, cartilage damage, synovial and serum factors. (4) Studies have also found monosodium urate crystal antibodies that form following the initial attack that may mediate and contribute to the onset of future attacks. (5,6)

Knowing that the great toe is the most common site of gout attacks, what kind of effect does surgery have on the great joint?  And more specifically, is a gout attack possible in the great toe joint following joint replacement?  Poorly treated cases of gout often result in great toe joint fusion or joint replacement.  In these patients with gout, is a gout attack possible following surgery?

In clinical practice, I’ve seen a number of cases of gout precipitated by injuries to the great toe joint.  The patient describes a benign injury, like stubbing their great toe or injuring it in sports.  Late that day, typically while sleeping on the night of the injury, the patients are awakened by and acute onset of pain far greater than what was found with the initial injury.  I’ve also seen surgical cases that result in an acute onset of a gout attack.  For instance, a simple bunionectomy results in the onset of gout.  In both of these cases, a known contributing local factor to the onset of gout is mechanical stress (injury or surgery) and untreated hyperuricemia.

If gout destroys the great toe joint and a fusion is chosen as the treatment of choice, I could understand that the mechanical stress of surgery could initially result in the onset of a gout attack if the patient went into surgery with hyperuricemia (elevated uric acid levels).  A year after the fusion surgery, once the fusion site has healed, the joint will have changed appreciably.  The synovial lining around the joint will atrophy resulting in tissue that no longer resembles a joint.  My assumption would be that the local issues that may contribute to the onset of a gouty attack post fusion procedure will be, to a great degree, eliminated.

Great toe implantIn the case of a great toe implant, the goal of the surgery is to maintain anatomical length of the great toe and maintain range of motion of the joint.  Although the majority of the articulating bone surfaces are resected in the implant surgery, the majority of the local factors that cause gout would remain (synovial joint lining and synovial fluid production).  That begs the question; after implant arthroplasty for gouty arthritis, could a gout attack occur?

A Google search using the terms ‘gout attack after implant surgery’ , ‘big toe implant gout’, ‘gout after surgery’ and ‘gout after great toe surgery’ found two articles describing postoperative  gout attacks but none specific to the onset of a gout attack following great toe implant arthroplasy. (7,8)

I have not seen a case of gout occurring in patient with chronic hyperuricemia either immediately status post implant arthroplasy of the great toe joint or weeks to months following great toe joint implant arthroplasy surgery.  I have to believe that a recurrent case of gout, following revision of the great toe joint with implant would be possible in the patient with chronic hyperuricemia.  Implant arthroplasty does little to mitigate the contribution of local factors and their influence of the onset of gout.

Prevention of hyperuricemia with diet or medications is the key to limiting the frequency of acute gouty attacks and preventing the arthritic destruction of the joint due to attacks.  If you do have a history of recurrent gout attacks, be sure to speak with your doctor to learn how to prevent this painful and destructive disease.

  1. Allen DJ, Milosovich G, Mattocks AM. Inhibition of monosodium urate needle crystal growth. Arthritis Rheum. 1965;8(6):1123–33. [PubMed] ]
  2. Loeb JN. The influence of temperature on the solubility of monosodium urate. Arthritis Rheum. 1972;15(2):189–92. [PubMed]
  3. Wilcox WR, et al. Solubility of uric acid and monosodium urate. Med Biol Eng. 1972;10(4):522–31.[PubMed]
  4. Martill MA, Nazzal L and Crittenden DB. The Crystallization of monosodium urate. Curr Rheumatol Rep. 2014 Feb; 16(2): 400.
  5. Kam M, et al. Antibodies against crystals. Faseb J. 1992;6(8):2608–13. [PubMed]
  6. 43. Kam M, et al. Specificity in the recognition of crystals by antibodies. J Mol Recognit. 1994;7(4):257–64. [PubMed]
  7. Napoli, D.  Post surgery gout attack risk factors identified.  MD Edge – Rheumatology News
  8. Lee EB. Ann. Rheum. Dis. 2007 Nov. 12 [Epub doi:10.1136/ard.2007.078683]

Jeff

Dr. Jeffrey Oster
Jeffrey A. Oster, DPM

Medical Director
Myfootshop.com

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