Controlling pain and hyperuricemia in patients with tophaceous gout after joints surgery

The primary treatment of tophaceous gout is to control the disease by pharmacological therapy. Additional surgical intervention is used to correct cosmetic deformation in joints or disabling functional disorder; however, one of its reported complications is hyperuricemia and recurrent attacks of pain. Objectives: to access the effectiveness of Low Intensity Laser therapy as addition to urate lowering treatment in patients with tophaceous gout, who underwent joints surgery in the Chengdu Rheumatism Hospital, in comparison to those patients who received only nonsurgical treatment. Subjects and methods. The effectiveness of Low Intensity Laser therapy (LILT) and urate lowering treatment in patients with tophaceous gout was investigated in 63 male patients of Chengdu Rheumatism hospital with tophaceous gout who underwent joints surgery. Control group was formed of 63 gout patients comparable in age and pre-treatment uric acid, who received non-surgical treatment.
Results. Patients underwent surgery in one or two sessions, the most common lesion site being foot joints: toes (49.41%), ankle (39.68%) and knee (34.92%), with restricted mobility in the mentioned joints. Levels of CRP before the treatment were elevated in almost all patients (median 3.74 (0.2, 48.75) mg/L), regardless of the other comorbidities. Urate lowering therapy notably reduced the levels of CRP to 2.44 (0, 33.27) mg/L in study group and to 1.3 (0.13, 31.72) mg/L in controls. After surgery and following urate lowering therapy all patients noted functional improvement and reduction of pain. Decrease in serum urate levels were reported in 96.83% of patients in study group and in 93.65% of controls. There was no significant difference in serum UA between patients who underwent joint surgery and who didn’t. Patients, who in addition to surgery received Low-Level Laser Therapy therapy, had a lowest mean serum UA after treatment (280.93 ± 97.05 μmol/L), but due to wide range of variation, difference to other groups wasn’t statistically significant. Addition of laser therapy also helped to reduce the pain almost twice (0.56±0.56 compared to 1.04 ± 0.91). However, we haven’t registered notable anti-inflammatory influence of LILT. There was a weak direct link established between levels of serum UA and CRP after treatment, but in patients receiving laser therapy, CRP was elevated more often, compared to those who weren’t prescribed with LILT or controls. Conclusion. Arthroscopic shaving and other surgical approaches focused on joints often doesn’t affect system hyperuricemia in any way and can’t be viewed as a substitute to urate lowering therapy. However, our experience confirms that timely performed surgery contribute to functional improvement and reduction of pain in gout patients. Low Intensity Laser therapy doesn’t affect hyperuricemia or guarantee long-term systemic anti-inflammatory effect, but help to additionally relieve pain in joints and thus enhance treatment effect and quality of patients’ life.

1. Khanna P.P., Nuki G., Bardin T. et al. Tophi and frequent gout flares are associated with impairments to quality of life, productivity, and increased healthcare resource use: Results from a cross-sectional survey. Health and Quality of Life Outcomes. 2012; 10 (1): 117. doi:10.1186/1477-7525-10-117.

2. McQueen F.M., Chhana A., Dalbeth N. Mechanisms of joint damage in gout: evidence from cellular and imaging studies. Nat. Rev. Rheumatol. 2012; 8 (3):173–81.

3. Ragab G., Elshahaly M., Bardin T. Gout: An old disease in new perspective – A review. J. Adv. Res. 2017; 8: 495–511.

4. Kasper I.R., Juriga M.D., Giurini J.M., Shmerling R.H. Treatment of Tophaceous Gout: When Medication is not Enough. Semin. Arthritis. Rheum. 2016; 45: 669–74.

5. Kumar S., Gow P. A survey of indications, results and complications of surgery for tophaceous gout. Journal of the New Zealand Medical Association. 2002; 115 (1158).

6. Lee S.S., Sun I.F., Lu Y.M. et al. Surgical treatment of the chronic tophaceous deformity in upper extremities – the shaving technique. J. Plast. Reconstr. Aesthet. Surg. 2009; 62 (5): 669–74.

7. Wang C.C., Lien S.B., Huang G.S. et al. Arthroscopic elimination of monosodium urate deposition of the first metatarsophalangeal joint reduces the recurrence of gout. Arthroscopy. 2009; 25 (2): 153–8.

8. Manpreet Singh, Kaushik Madan L. A Review on Treatments of Gout for Future Aspects. Research and Reviews: A Journal of Pharmaceutical Science. 2017; 8 (3): 1–6.

9. Khanna D., Fitzgerald J.D., Khanna P.P. et al. American College of Rheumatology guidelines for management of gout. Part 1: systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia. Arthritis Care Res (Hoboken). 2012;64 (10):1431–46.

10. Felizatti A.L., Bomfim F.R., Bovo J.L. et al. Effects of low-level laser therapy on the organization of articular cartilage in an experimental microcrystalline arthritis model. Lasers in Medical Science. 2019; 34 (7): 1401–1412. doi:10.1007/s10103-01902740-5.

11. Castano A.P., Dai T., Yaroslavsky I. et al. Low-level laser therapy for zymosan-induced arthritis in rats: Importance of illumination time. Lasers in Surgery and Medicine. 2007; 39 (6): 543–550. doi:10.1002/lsm.20516.

12. Campana V.R., Moya M., Gavotto A. et al. Laser Therapy on Arthritis Induced by Urate Crystals. Photomedicine and Laser Surgery. 2004; 22 (6): 499–503. doi:10.1089/pho.2004.22.499.

13. Rodriguez-Silva B.A., Carrillo-Delgado C.M., HernandezGarcia J.C. et al. Photochemical decomposition of uric acid crystals by ultra-short laser pulses. Optical Interactions with Tissue and Cells XXXI. 2020. doi:10.1117/12.2546099.

14. Yan D., Zhang Y. Personalized Medicine of Urate-Lowering Therapy for Gout. Recent Advances in Gout. 2020. doi:10.5772/intechopen.85030.