ARTHKII'IS & I<HEUMAIISM
Vol. 39, No. 8. August 1996, pp 1406-1409
1406
COMPUTED TOMOGRAPHY OF THE KNEE JOINT AS
AN INDICATOR OF INTRAARTICULAR TOPHI IN GOUT
JEAN C. GERSTEK, MICIIEL LANDRY, BERTRAND DUVOISIN, and GEORGES RAPPOPOR?'
Objective. To evaluate the utility of computed
tomography (CT) of the knee joint for detecting intraar-
ticular tophaceous deposits.
Methods. A prospective study of 16 patients with
gout affecting the knee was conducted. A condition for
inclusion in the study was the presence of needle-shaped
crystals with negative birefringence in the knee joint
synovial fluid. Conventional radiography and CT were
performed in each case.
Results. Intraarticular opacities in the capsule
and the synovium, consistent with the presence of
tophaceous deposits, were found in 5 of the 16 patients
(9 knee joints). The mean duration of gout was longer in
the patients with intraarticular tophi than in those
without tophi, and 2 of the patients with tophi had poor
tolerance to antihyperuricemic therapy.
Conclusion.Intraarticular opacities considered to
represent tophi were observed in approximately one-
third of the patients. The presence of tophi correlated
with a longer duration of the disease and a poor
tolerance to medication. We therefore suggest that CT of
the knees could be useful in the assessment and fol-
lowup of certain patients with gout.
While conventional radiography reveals calcifica-
tions of t h e menisci or hyaline cartilage in various
arthropathies, it is generally not useful for detecting
m o n o s o d i u m u r a t e m o n o h y d r a t e (MSU) crystal deposits
because thesc arc not sufficiently o p a q u e . Howcver, in
s o m c cases of gout, radiography m a y reveal asymmetric
swelling within a joint a t a n early stagc of t h e disease or
subcortical cysts in more advanced cases (1). T h e a i m of
t h e present study was to evaluate t h e utility of c o m p u t e d
~
Jean C. Gcrster, MD,Michcl I>andry,MD. Bcrtrand Duvoi-
sin, MD, Cieorgcs Kappoport, MD: Ccntre I Iospitalicr Universitaire
Vaudois, Lausanne. Switzcrland.
Address reprint requests to Jean C. Gcrster, MD, Scrvicc d e
Khumatologic, Mtdccine Physique ct Kehabilitation, CHUV, 1011
Lausannc. Switzerland.
Submitted for publication September 25, 19%; accepted in
revised form March 13, 1996.
G 1996, American College of Rheumatology
tomography (CT)for depicting intraarticular tophi, with
emphasis on t h e k n c c joint b e c a u s e it is t h e largest joint
of t h e body.
PATIENTS AND METHODS
Sixteen malc patients with gout involving one or both
knees, who wcre seen at our rheumatology center over a period
of 10 months, wcrc studied. All fulfilled the diagnostic criteria
for gout establishcd by Wallace et a1 (2). Their mcan agc was
60.3 ycars (rangc 40-90 ycars). Their mean duration of gout
was 9 ycars (rangc 1-25 years). All but 1 of thc patients had
other joints, in addition to the knce, affectcd by gout. Subcu-
taneous tophi were present in 6 patients. Prepatellar gouty
bursitis was noted in 2. O n palpation, no indurated mass within
the knee joint or Baker's cyst was found in any of the patients.
In all cases, analysis of synovial fluid from the knee had
rcvealed nccdle-shapcd crystals with negative bircfringence on
polarized light microscopy, and no positive birefringcnt crystals
suggestive of calcium pyrophosphatc dihydratc crystal deposi-
tion disease.
Information on the prcscnce of subcutaneous tophi
was recorded for each patient. Current therapy for gout was
noted, as were risk factors for gout, such as excessivc alcohol
consumption or intake of rncdications such as diurctics or
cyclosporine. All patients undcnvent convcntional antcropos-
terior and lateral radiography of the kncc joints in order to
exclude thosc with radiologic signs of chondrocalcinosis.
At the intercritical phases of gout, C1'was performed
with a 9800 High Spccd Advantage GE scanner, using 120 kV,
140 mA, and 1 mm collimation (table spccd I mm/s, pitch 1).
For each knee joint, 2-dimensional reconstruction was pcr-
formed with a standard algorithm, and 2 scts of imagcs were
obtained: thc first one with a soft tissue window, the sccond
with a bone window. In addition, 3-dimcnsional reconstruction
with surface display (3) was carried out in each casc.
Large tophi spontaneously rclcascd from the hands of
a paticnt with severe ulcerating tophaceous gout (Figure 1A)
were immersed in water and tested successively by radiography
and CT. Specimens from thcsc tophi, examined by x-ray
diffraction and infrared spectroscopy, proved to consist of pure
-
MSU (NaH C,H,O,N, * T3,O). Comparison of radiographs
and C T images of MSU tophi in vitro showed that the tophi
wcre nearly radioluccnt on radiographs (Figure lB), but were
of clearly greater attcnuation than soft tissue o n LT (Fig-
ure 1C).
CT OF THE KNEE IN GOUT 1407

femorotibial osteoarthritis in a third. In none of the

Figure 1. Monosodium urate monohydrate tophi in a plastic tube. A,
Macroscopic appearance. B, Radiograph taken with 40 kV. The tophi
are barely visible. C, Computed tomography image taken with 120 kV.
The tophi are clearly delineated (mean 2 2 SD density 170 + 30
Hounsficld units).
RESULTS
Conventional radiography revcaled faint fluffy
opacities around the knee joints in 1 patient, signs of
femoropatellar ostcoarthritis in another, and signs of
patients were punched-out erosions, subchondral cysts,
or a pronounced osteophytosis observed. In 5 patients,
CT showed capsular or intraarticular macroscopic round
opaque masses consistent with tophaceous deposits (9
knee joints). These masses measured 170 2 30
Hounsficld units (HU; mean t 2 SD) (the density of the
tophi shown in Figure 1 being in the same range). They
werc located mainly laterally or medially, and it ap-
peared that thc synovium was involved. Figures 2 and 3
illustrate 2 cascs.
The mean duration of gout in the 5 patients in
whom CT revealed tophaccous masses was 14 ycars
(range 1-25 years). Two had olecranon subcutaneous
tophi. Of the 4 patients who had been treated with
allopurinol, 2 were intolerant to this medication. A
patient who had had gout for only 1year had been taking
and was still taking cyclosporine for renal transplanta-
tion performed 6 years previously. One patient was
ernploycd as a floor layer.
In the remaining 11 patients (4 with subcutane-
ous tophi), intraarticular opacities were not seen; it
should bc noted, however, that 2 of them showed signs

A B
Figure 2. A, Two-dimensional computed tomography (CT) image of the right knee of a 49-year-old man with gout of 25 years duration, showing
bilateral ground-glass paracondylar opacitics containing more opayuc spots (mean 2 2 SD density 170 2 30 Hounsfield units), the lateral one
causing a bony erosion with an overhanging edge (arrow). B, Three-dimensional CT image of the right knce of the same patient as in A.
Conglomerations of tophi are seen abutting the lateral and medial condyles.
1408 GERSTER ET AL

A B
Figure 3. A, Two-dimensional computed tomography (CT) image of the left knee of a 50-year-old man with gout of 1 year duration who had
received long-term treatment with cyclosporine, showing extensive, large opacities (mean 5 2 SD density 170 ? 30 Hounsfield units), mainly of the
lower intercoridylar notch (arrow). B, Thrce-dimensional CT image (posterior view) of the left knee of the same patient as in A, showing that the
opacities are located in the posterior cruciate ligamcnt (arrow). Paracondylar tophi are also seen.

of prepatcllar bursitis with bursa1 radiodcnse collection
on CT, considered to represent MSU crystal dcposits.
Thc mean duration of gout in these patients was 6.8
years (range 1-16 years).
DISCUSSION
MSU crystals arc known to dcposit in the syno-
vium and in periarticular structures (4-6) and can be
easily observed during arthroscopy (7). This study fo-
cused on thc knee joint becausc of its large size. CT was
uscd bccausc of its contrast resolution capability (Figure
1C). Our rcsults clearly dcmonstrate that tophi can
develop in the knee, usually without symptoms, causing
major changcs and reaching a large size without being
evident on physical cxamination. Thcy can even be
found in subjects without subcutaneous tophi.
Increased attenuation of the x-ray beam of the
CT scanner, as reflectcd by an increased I-IU value,
could be due to a high concentration of sodium nuclci in
thc MSU crystals. Moreover, CT could be a useful
technique in distinguishing tophi from xanthomas, the
latter being of much lower dcnsity on CT (40-60 HU) (8).
Subcutancous tophi tend to occur in patients with
more severe gout (1). In our 5 paticnts, intraarticular
tophi seem to corrclate with longer duration of the
diseasc, with poor tolerance to antihyperuricemic thcr-
apy, and in 1 case, with administration of cyclosporine
thcrapy; cyclosporine is well known to induce hyperuri-
cemia and gout (9).
These cascs illustrate that tophi can bc present in
the knee joint cavity and remain asymptomatic. Thcy
might also be the origin of MSU crystals relcascd in
synovial fluid, as observed in many cascs of chronic gout
with persistcnt low-gradc noninflammatory joint effusion
in an intercritical phase (10). The absence of a clinical
inflammatory response dcspite the presence of MSU
crystals remains unexplained (11).
CT is a noninvasive tcchnique that can be used to
reveal intraarticular tophi as shown in this study. It could
be uscful in asscssing the scverity of gout and in moni-
toring patients being treatcd for the disease: regression
or disappearance of intraarticular tophi might be indic-
ative of trcatrnent efficacy (12). Howevcr, in view of its
cost, it should be rcscrved for selected scvcrc cases. It
CT OF THE KNEE IN GOUT
certainly should help in the future to document patho-
logic conditions associated with tophaceous deposits not
only in intraarticular, but also in extraarticular locations
such as the carpal tunnel (13), Achilles’ tcndon (14), or
spine (15).
ACKNOWLEDGMENTS
Thc authors wish to thank Ms Liliane Dufresne of the
Institut Univcrsitaire de Mineralogie, Lausanne, for perform-
ing infrared spectroscopy and x-ray diffraction analysis.
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