Gout

The main symptoms are joint pain, redness, swelling, fever and chills.

The first joint commonly affected is the big-toe metatarsophalangeal joint.

Sometimes hallux valgus occurs together with gout. In such cases, patients often incorrectly attribute their hallux-valgus symptoms to the deformity, without realising that gout, rather than the deformity itself, is the main cause of their complaints.

In its natural course, the disease can pass through 1 of 4 phases:

• an asymptomatic phase despite an elevated serum urate level (hyperuricaemia). Its duration varies between patients, and most people with hyperuricaemia never develop fully symptomatic gout
• acute attacks of arthritis with very severe pain, redness and swelling around the joints. These symptoms develop rapidly, often after a dietary indiscretion. Patients who have had a gout attack are at risk of another attack within 6–24 months
• intercritical periods
• chronic gout in advanced disease, usually developing 5–10 years after onset. This phase is characterised by chronic pain and restricted joint movement

Gout is caused by an elevated blood uric-acid level, that is, hyperuricaemia.

Hyperuricaemia may be:

• primary, caused by a genetic defect in enzymes responsible for purine metabolism 
• acquired, associated with increased production or reduced excretion of uric acid

Causes of acquired hyperuricaemia:

• increased dietary purine intake: meat, offal, seafood, asparagus, spinach, beans and mushrooms; excessive consumption of spirits and beer (wine has no effect)
• use of medicines that increase uric-acid levels (aspirin at certain doses)
• previous serious illnesses, such as cancer, heart attack, epilepsy, respiratory failure, hypothyroidism, hyperparathyroidism, transplants, obesity, diabetes, coronary disease, hypertension, ischaemic heart disease, lipid disorders, injuries and dehydration

• During a gout attack, treatment consists of colchicine and anti-inflammatory medicines
• Preventive treatment consists of avoiding foods that trigger attacks; when attacks recur frequently, low-dose colchicine is used long term
• Treatment to lower uric acid consists of medicines that increase renal excretion of uric acid or reduce its production in the body

Surgical treatment of gout

This involves removing large gouty tophi, especially from areas exposed to irritation

Long-term inflammation causing joint destruction requires surgery in the form of arthroplasty or arthrodesis (for a foot metatarsophalangeal joint)

In foot surgery, ensuring a pain-free operation and minimising postoperative pain have always been major challenges.

It is commonly believed that recovery after foot surgery, especially hallux surgery, is very painful.

There are many options for anaesthesia during procedures on the foot.

Modern anaesthesiology aims, wherever possible, to use regional anaesthesia techniques – from central blocks such as spinal and epidural anaesthesia, commonly known as lumbar anaesthesia, to peripheral nerve blocks at various levels performed under ultrasound guidance, especially when operating on one foot.

The possibility of using a particular type of anaesthesia depends mainly on the extent of surgery and any coexisting conditions.

The final choice of anaesthesia is agreed with the patient during the preoperative assessment interview.

Using ultrasound in anaesthesiology to perform peripheral nerve blocks has enabled highly precise regional anaesthesia.

Our many years of experience have changed our perioperative approach, both to anaesthesia itself and to the postoperative period.

For foot surgery, peripheral nerve anaesthesia, known as an ankle block, means injecting a local anaesthetic around the nerves at the appropriate level.

These anaesthetics are highly precise because the nerves responsible for pain sensation are clearly visible on ultrasound and medication delivery is fully controlled.

This can substantially reduce or even eliminate the need for pain medication early after surgery.

For many patients, one of the most important advantages is that sensation above the knee is preserved in the operated leg and, most importantly, lumbar anaesthesia is avoided, which patients do not always accept.

Another important advantage is that walking can begin very soon after the procedure.

During the postoperative period, administering pain medication at regular intervals under ultrasound guidance around the nerves responsible for pain enables patients to pass through this period as comfortably and painlessly as possible.