Tophaceous Lesions Research Articles

Middle Ear Tophi: A Case Series of Two Unusual Lesions and a Report of Facial Weakness and Review of the Literature.

Tophaceous lesions of the middle ear from calcium pyrophosphate deposition disease (CPPD, or pseudogout) and gout are infrequently reported. Recognizing its characteristic findings will allow clinicians to accurately narrow the differential diagnosis of bony-appearing middle ear lesions and improve management. Two consecutive cases of tophaceous middle ear lesions presenting to a tertiary care center between January 2021 and December 2021. Neither with previous rheumatologic history. Surgical excision of tophaceous middle ear lesions. Improvements in facial weakness and conductive hearing loss. The first case was a 66-year-old gentleman with progressive conductive loss, ipsilateral progressive facial weakness over years, and an opaque, irregular-appearing tympanic membrane anterior to the malleus found to have CPPD on surgical pathology, with immediate postoperative improvement of facial function. The second was a 75-year-old gentleman with progressive conductive loss and similar appearing tympanic membrane as case 1, previously diagnosed with tympanosclerosis, found to have gout on surgical pathology. In both cases, the CT showed a heterogenous, bony-appearing lesion in the middle ear, and both tophaceous lesions were a of gritty, chalky consistency intraoperatively. Tophaceous lesions of the middle ear are rare but have similar findings. Notably, the tympanic membrane can appear opaque and irregular, and the CT demonstrates a radiopaque, heterogeneous appearance. Facial weakness is an unusual finding. Specimens of suspected tophi must be sent to pathology without formalin for accurate diagnosis.

Early Shaver Surgical Treatment of the Chronic Tophaceous Masses Effectively Remove the Lesions Without Major Complication

Background: Gout is a modern-day chronic disease seen in 4·62% of Taiwan’s general population. Although the current treatment of urate lowering therapy (ULT) is effective, there remains 10% of patients who do not response well for this treatment. This paper reviews the effectiveness of the shaver technique, which not only increases efficacy when coupled with ULT but can also be used individually to treat the 10% subset that suffer from chronic tophaceous lesions. Method: Using PubMed, all available series of surgery for tophaceous gout were reviewed. Statistical analysis was performed on our surgical outcomes of patients treated by the shaver technique over a sixteen-year (2002 to 2018) period. Finding: The key to shaver technique is early intervention to prevent joint function deterioration. Statistical analysis showed that infection and surgery sites directly correlate to the prognosis of gout patients. Moreover, 6 published surgical articles were identified. All 6 articles were published between 2009 and 2019. The reported outcome of surgical intervention for gout was positive with satisfactory cosmetic outcome and faster recovery period. Interpretation: Although ULT is currently used as the first-line approach to tophaceous gout, we believe the shaver technique should be implemented at the early phase of tophaceous gout lesions, thereby preventing excessive damage in the joints, but also the complication of the shaver technique is minor compared to other available surgical options. Funding: This study was authors’ own work. Declaration of Interests: No conflicts of interests to be disclosed. Ethics Approval Statement: The study was approved by Institutional Review Board at Kaohsiung Medical University.

Gadolinium-enhanced MRI features of acute gouty arthritis on top of chronic gouty involvement in different joints

The aims of the current study are to describe gadolinium-enhanced MRI features of an acute flare of established gouty arthritis in different joints and to examine a possible association between serum uric acid and MRI signs indicative of ongoing inflammation and/or structural joint damage as well as association with disease characteristics and laboratory findings. Twenty-seven male patients with established chronic gout agreed to participate, mean age 47.6 years, and mean disease duration in months 43.2 (±31.8). For all patients, detailed demographic, disease characteristics, and laboratory findings were obtained and correlated with MRI findings. In 27 patients with established gout, a total of 50 MRI studies were performed of the following joints: feet joints (n = 23), ankles (n = 18), knees (n = 5), and hand and wrist joints (n = 4). MRI revealed capsular thickening in 19 patients, bone marrow edema (BME) in 15, soft tissue edema (STE) in 20, joint effusion in 21, bone erosions in 17, cartilaginous erosions in 4, and tenosynovitis in 9 cases. In 17 cases, tophaceous lesions were found. Post contrast MRI showed synovial thickening in seven cases. Positive correlations were observed between serum uric acid levels and the following MRI findings: capsular thickening (r = 0.552, p = 0.003), BME (r = 0.668, p ≤ 0.0001), STE (r = 0.559, p = 0.002), and tenosynovitis (r = 0.513, p = 0.006). Using MRI in chronic gout, important features can be detected like BME, minute cartilaginous erosions, and hypertrophic synovial inflammation in post contrast MR images. Serum uric acid (SUA) was positively correlated with capsular thickening, BME, STE, and tenosynovitis.

Acute Comminuted Pathologic Fracture of a Hallucal Sesamoid with Tophaceous Gout: A Case Report.

Fractures in the sesamoid bones may occur by direct trauma or repetitive overuse (stress fractures). Acute fracture of the hallucal sesamoids is seen most often with dislocation of the metatarsophalangeal joint after a high-energy injury1. A chronic stress fracture of the sesamoid bone is generally found in athletes and can be difficult to differentiate from other conditions that affect the hallucal sesamoids2. The optimal choice of treatment remains unclear3. In chronic tophaceous gout, urate deposition may occur in articular cartilage, subchondral membranes, joint capsules, and periarticular tissues. An isolated intraosseous tophaceous lesion in the hallucal sesamoids is rare4-7. We found only one previously published report describing a chronic stress fracture and nonunion of a hallucal sesamoid that was associated with tophaceous gout8. To our knowledge, there have been no previously published reports of an acute comminuted pathologic fracture of a hallucal sesamoid with a tophaceous deposit. We describe a rare case of an acute comminuted pathologic fracture with tophus of the fibular sesamoid in a young soldier with no history of gout or underlying systemic disorder. The patient was informed that data concerning the case would be submitted for publication, and he provided consent. A twenty-year-old soldier with no history of gout noted a painful disability of the right forefoot during a military march. The pain persisted for several days, and he was not able to bear weight in the standing position. He noted that he had experienced similar forefoot pain three years prior; he had also experienced similar symptoms several times before, but with less intensity. The pain increased during forced dorsiflexion of the …

First Metatarsophalangeal Joint Arthrodesis for the Treatment of Tophaceous Gouty Arthritis

In tophaceous gouty arthritis, surgeons face the choice between preservation of the involved joint and arthrodesis after tophi excision. Magnetic resonance imaging (MRI) can allow evaluation of the distribution of tophaceous deposits, which can be difficult to visualize on radiography. The goal of this study was to evaluate the characteristic MRI features of tophaceous lesions and to compare the clinical outcomes of arthrodesis after tophi excision with those of simple tophi excision. The authors reviewed 16 feet in 15 consecutive patients diagnosed with tophaceous gouty arthritis of the first metatarsophalangeal (MTP) joint who underwent surgery. Nine feet (group A) were treated with simple tophi excision, whereas the other 7 (group B) underwent first MTP joint arthrodesis after tophi excision. For clinical evaluation, the visual analog scale (VAS) for pain, American Orthopaedic Foot and Ankle Society (AOFAS) score, Tegner activity scale, and patient satisfaction assessments were used. Magnetic resonance imaging was performed to evaluate the characteristics of tophaceous deposits in the first MTP joint. Mean VAS and AOFAS scores and patient satisfaction significantly differed between the 2 groups at final follow-up (P=.007, .005, and .002, respectively). In group A, progression of arthritis of the first MTP joint was observed in 6 of 9 cases at final follow-up. The tophaceous lesions of these 6 cases were found to be located intra-articularly on MRI. Arthrodesis after tophi excision should be considered for treating tophaceous gouty arthritis of the first MTP joint when tophi are located intra-articularly and loss of cartilage involved is greater than 50% of the entire joint.

The �Chalky Culprit� of acute locked knee

Acute locked knee is commonly caused by tears of the menisci in the knee, osteochondral injuries and also by the stump of a ruptured anterior cruciate ligament. We present two cases of acute locked knee atypically caused by gouty tophaceous lesions in the knee.

Tophaceous Gout of the Knee

To evaluate the locations and associated erosions of tophaceous gout in the knee and to reevaluate its characteristic magnetic resonance imaging features. We performed a retrospective review of the magnetic resonance (MR) images of the knees of 30 patients with histopathologically confirmed gouty tophi. Each tophaceous lesion was evaluated for location, morphology, signal intensity, and associated bone erosion or intraosseous involvement. The tophaceous masses were commonly located on the medial aspect of the infrapatellar fat pad and anterior joint recess (n = 28, 87%), the space adjacent to the lateral rim of the lateral femoral condyle (n = 25, 78%), and the intercondylar fossae (n = 22, 69%). All tophaceous lesions showed similar signal characteristics (low-intermediate signal intensities on T1-weighted images, with heterogeneous signal intensities on T2-weighted images), and 3 morphologic patterns were observed: amorphous masses (n = 27), linear crystalline-like deposits (n = 6), and cystic lesions of the bursae around the knee (n = 3). Associated bone erosions occurred in the lateral rim of the lateral femoral condyle (n = 8), the roof of the intercondylar notch (n = 7), the tibial eminence (n = 5), and the medial and lateral rim of the tibial plateau (n = 3). Intraosseous tophi were seen in the tibial plateau (n = 3) and patella (n = 1). Knowledge of the common locations and associated erosions of tophaceous gout and its characteristic MR appearance may facilitate its correct diagnosis with magnetic resonance imaging, particularly in patients with no clinical symptom or only an isolated lesion on MR images.

Surgical treatment of the chronic tophaceous deformity in upper extremities – the shaving technique

Tophaceous gout is frequently directly related to the duration and the severity of hyperuricaemia. Conventional surgical debridement of the tophaceous lesions carries the risk of overlying skin necrosis. Life-long urate-lowering drugs have become the mainstay of primary treatment. However, surgical intervention may be necessary when the overlying skin becomes ulcerated and wound infection develops. This has become the impetus for new surgical treatment methods with less potential for morbidity. From November 2000 to July 2006, 32 patients with chronic tophaceous deposits involving their hands or elbows were treated surgically in our hospital. In this series, a soft tissue shaver device with a mini-incision technique was used to treat upper extremity tophaceous lesions. Multiple 5-mm skin incisions were made to allow direct access to the tophaceous mass. Intra-lesion shaving was done. A tourniquet aided reduction of intraoperative blood loss. Suction and irrigation were performed simultaneously while the shaver system was operating; the chalky deposits of sodium urate were thereby removed efficiently. No major complications were noted among these 32 patients. Using this shaver technique, each tophaceous lesion was removed in less than 15 min. Twenty-nine of these operations (80.6%) were performed for patients at the intercritical gout phase. Two patients suffered a recurrent acute attack of gouty arthritis within 12h after the operation. Symptoms were controlled by oral colchicine as well as nonsteroidal anti-inflammatory drugs (NSAID). Swelling at the operative site was usually evident for the first 10 days postoperatively, therefore posture drainage is advised. The shaver technique provides another option in the surgical treatment of tophaceous lesions. It prevents poor wound healing associated with tendon or joint exposure that often occurs after conventional enucleating procedures. The tophaceous lesions can be treated surgically at the intercritical gout phase. Also, the upper extremity group has a shorter hospitalisation period when compared with our preliminary study involving treatment of tophaceous deposits in the lower extremity. The shaver technique is worthy of consideration in the treatment of upper extremity chronic tophaceous patients.

Tophaceous Lesion of the Middle Third of the Nose

Dermatologic SurgeryVolume 32, Issue 4 p. 556-557 Tophaceous Lesion of the Middle Third of the Nose PIER C. PARODI MD, PIER C. PARODI MD All authors are affiliated with Department of Plastic Reconstructive Surgery, University of Udine, Udine, ItalySearch for more papers by this authorFABRIZIO DE BIASIO MD, FABRIZIO DE BIASIO MD All authors are affiliated with Department of Plastic Reconstructive Surgery, University of Udine, Udine, ItalySearch for more papers by this authorBARBARA NADALIG MD, BARBARA NADALIG MD All authors are affiliated with Department of Plastic Reconstructive Surgery, University of Udine, Udine, ItalySearch for more papers by this authorSILVIA RICCI MD, SILVIA RICCI MD All authors are affiliated with Department of Plastic Reconstructive Surgery, University of Udine, Udine, ItalySearch for more papers by this author PIER C. PARODI MD, PIER C. PARODI MD All authors are affiliated with Department of Plastic Reconstructive Surgery, University of Udine, Udine, ItalySearch for more papers by this authorFABRIZIO DE BIASIO MD, FABRIZIO DE BIASIO MD All authors are affiliated with Department of Plastic Reconstructive Surgery, University of Udine, Udine, ItalySearch for more papers by this authorBARBARA NADALIG MD, BARBARA NADALIG MD All authors are affiliated with Department of Plastic Reconstructive Surgery, University of Udine, Udine, ItalySearch for more papers by this authorSILVIA RICCI MD, SILVIA RICCI MD All authors are affiliated with Department of Plastic Reconstructive Surgery, University of Udine, Udine, ItalySearch for more papers by this author First published: 24 April 2006 https://doi.org/10.1111/j.1524-4725.2006.32113.x Address correspondence and reprint requests to: Dott. Fabrizio De Biasio, c/o Clinica di Chirurgia Plastica, Via Battiferro, 33014 Gemona del Friuli (UD), Italy, or e-mail: fdebiasio@hotmail.com. Read the full textAboutPDF ToolsExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume32, Issue4April 2006Pages 556-557 RelatedInformation

Tophaceous Lesion of the Middle Third of the Nose

PARODI, PIER C MD; DE BIASIO, FABRIZIO MD; NADALIG, BARBARA MD; RICCI, SILVIA MD* Author Information

MR imaging in gout

The appearance of gouty tophus in magnetic resonance imaging (MRI) is characteristic. On T1- and T2-weighted SE images, the signal intensity of tophaceous lesions is similar to that of muscles. According to the histology, T2-weighted SE images demonstrate extremely hyperintense signals, which reflect the high protein content in the amorphous center of the tophus. The microscopic urate crystals deposited there have no MRI signal and are of no further diagnostic impact. Vascularized granulation tissue surrounding the tophus center enhance after intervenous application of contrast agents (Gadolinium). The inflamed tophus is associated with local edema, causing high signal intensity. MRI is superior to plain radiography for early detection of intraosseous tophi. Involvement of anatomical structures such as ligaments and tendons can be evaluated sufficiently. For peripheral joints, axial slice orientation is most helpful.

A radiologic reevaluation of gout: a study of 2,000 patients

Radiographs were available for study for 466 of 2,000 patients with primary gout who were followed clinically for as long as 30 years. The radiographic manifestations at various stages of the disease and the effect of therapy were studied in 80 patients. New radiographic signs, such as lace pattern, intracortical lesions, and subchondral compressions, are emphasized as well as the frequency of tophaceous lesions affecting the dorsum of the feet.