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Bilateral First-Ray Amputation of the Foot Due to Severe Tophaceous Gout Complicated by Infection and Discharged Sinus

A Case Report

Kerim Sariyilmaz Department of Orthopedics and Traumatology, Acibadem University Atakent Hospital, Istanbul, Turkey.

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Ilker Eren Department of Orthopedics and Traumatology, Koc University Hospital, Istanbul, Turkey.

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Okan Ozkunt Department of Orthopedics and Traumatology, Acibadem University Atakent Hospital, Istanbul, Turkey.

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Mustafa Sungur Department of Orthopedics and Traumatology, Acibadem University Atakent Hospital, Istanbul, Turkey.

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Onder I. Kilicoglu Department of Orthopedics and Traumatology, Istanbul University, Istanbul Medical Faculty, Istanbul, Turkey.

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Fatih Dikici Department of Orthopedics and Traumatology, Acibadem University Atakent Hospital, Istanbul, Turkey.

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Background:

Gout is a purine metabolism disease. Tophaceous gout may cause joint destruction and other systemic problems and sometimes may be complicated by infection. Infection and sinus with discharge associated with tophaceous gout are serious complications, and treatment is difficult. We present a patient with tophaceous gout complicated by infection and discharging sinus treated by bilateral amputation at the level of the first metatarsus.

Methods:

A 43-year-old man previously diagnosed as having gout, and noncompliant with treatment, presented with tophaceous gout associated with discharging sinus and infection on his left first metatarsophalangeal joint. Because of the discharging sinus associated with the tophaceous deposits, the soft-tissue and bony defects, and the noncompliance of the patient, amputation of the first ray was undertaken, and a local plantar fasciocutaneous flap was used to close the defect. After 8 months, the patient was admitted to the emergency department with similar symptoms in his right foot, and the same surgical procedure was performed.

Results:

One year after the second surgery, the patient had no symptoms, there was no local inflammatory reaction over the surgical areas, and laboratory test results were normal.

Conclusions:

Gout disease with small tophi often can be managed conservatively. However, in patients with extensive lesions, risk of superinfection justifies surgical treatment. Results of complicated cases are not without morbidity; therefore, early surgical treatment may prevent extremity loss and further complications. In severe cases, especially with compliance issues, amputation provides acceptable results.

Corresponding author: Kerim Sariyilmaz, MD, Department of Orthopedics and Traumatology, Acibadem University Atakent Hospital, Halkali Merkez Mahallesi Turgut Ozal Bulvari No:16, Kucukcekmece, Istanbul, 34303 Turkey. (E-mail: ksariyilmaz@gmail.com)