GOUT AND PSEUDOGOUT

Surgery is a risk factor for development of crystal arthropathy, or for a flare of preexisting crystal arthropathy.  Gout is in the differential diagnosis of postoperative fever—often the patient’s joint exam is ignored, especially in patients slow to mobilize or who cannot give a history, while an extensive fever workup is performed.  Gout should be considered in patients with joint pain, unexplained fever, leukocytosis, or difficulty with physical therapy. 

Preoperative assessment:

• Generally continue prophylactic medications (e.g. allopurinol) up until surgery and resume postoperatively when able.

Postoperative management:

• Attention to adequate volume repletion.
• New meds may induce gouty attack (e.g. diuretics, cyclosporine).
• Mobilization.

For an acute arthritis, consider:

• Location—crystal arthropathies are often in large joints (e.g. knee, ankle).
• Confirming diagnosis with arthrocentesis.
• Assess clinical suspicion for septic joint—arthrocentesis may be needed to rule out infection, as opposed to ruling in crystal disease.
• Pseudogout is common.

Pseudogout: 
Making a diagnosis of pseudogout is important to avoid unnecessary uric-acid lowering therapy.  X-rays may show calcium pyrophosphate deposition, but this finding is neither specific nor sensitive for pseudogout.  Arthrocentesis remains the gold standard.   This diagnosis should strongly be considered in a postoperative patient with acute knee arthritis.

Treatment of acute postoperative gout or pseudogout (generally same for both):
Unfortunately, typical medications used to treat acute crystal arthropathy may be relatively contraindicated in the immediate postoperative setting—always work with the surgery team. 

• Consider intra-articular injection.
• NSAIDs—may be contraindicated if renal failure or surgical bleeding risk.
• Prednisone—may be contraindicated for concerns of wound healing, hyperglycemia, and infection risk.
• Colchicine—GI side effects may limit use in patients post abdominal surgery.

For difficult cases, consultation with Rheumatology is indicated.

 

 

Updated May 2011