Gouty Arthritis Joint Replacement: What to Expect

Quick Take

• Gouty arthritis can damage joints enough to need a joint replacement.
• Hip and knee are the most common sites for surgery in gout patients.
• Pre‑op planning focuses on controlling uric acid levels and coordinating rheumatology and orthopaedics.
• Hospital stay is usually 2‑4 days; full rehab takes 3‑6 months.
• Long‑term success hinges on medication adherence, diet, and guided physiotherapy.

Understanding Gouty Arthritis

Gouty arthritis is a form of inflammatory arthritis caused by the accumulation of uric acid crystals in the synovial fluid of joints, triggering sudden, excruciating pain, swelling, and redness. It most often strikes the big toe, but chronic attacks can spread to the ankles, knees, hips, and elbows. Over time, the crystal deposits erode cartilage and bone, leaving the joint stiff and deformed. While lifestyle changes and urate‑lowering drugs can halt progression, some patients eventually need surgery to restore function.

Key triggers include high‑purine foods, alcohol, dehydration, and certain medications. The hallmark laboratory finding is serum uric acid above 6.8mg/dL, and joint aspiration will reveal needle‑shaped monosodium urate crystals under polarized light microscopy.

When Surgery Becomes an Option

Deciding on surgery is never taken lightly. An orthopaedic surgeon and a rheumatologist work together to evaluate:

• Degree of joint destruction on X‑ray or MRI.
• Frequency and severity of gout flares.
• Response to urate‑lowering therapy (allopurinol, febuxostat, or pegloticase).
• Overall health, including heart, lung, and kidney function.

Types of Joint Replacement for Gout Patients

The two most common procedures are hip and knee replacements. Both replace the damaged bone and cartilage with prosthetic components, but the surgical approach and post‑op protocols differ slightly.

Hip replacement involves removing the femoral head and acetabular socket, then inserting a metal‑on‑plastic or ceramic‑on‑ceramic bearing. The incision is typically 8‑12cm, and many surgeons now use a minimally invasive anterior approach to spare muscles.

Knee replacement (total knee arthroplasty) replaces the distal femur, proximal tibia, and often the patellar surface with metal and polyethylene components. Surgeons may choose a cruciate‑retaining or posterior‑stabilised design depending on ligament integrity.

Preparing for Surgery

Preparation starts months before the operation:

1. Control uric acid levels. Aim for serum uric acid < 5mg/dL for at least six weeks. Your rheumatologist may adjust allopurinol dosage or add a short‑term colchicine bridge.
2. Review medications. Aspirin, NSAIDs, and some anticoagulants increase bleeding risk and are usually stopped 5‑7 days prior.
3. Optimise comorbidities. Diabetes, hypertension, and chronic kidney disease should be well‑controlled to lower infection risk.
4. Pre‑op imaging. Standard AP and lateral X‑rays confirm component size; CT may be ordered if severe deformity exists.
5. Physical conditioning. Light cardio, quad‑strengthening, and flexibility exercises improve post‑op mobility.

During the pre‑op visit you’ll meet two key specialists:

Rheumatologist oversees gout management, ensuring crystal burden is minimal before cutting into the joint.

Orthopedic surgeon explains the surgical technique, prosthetic options, and expected outcomes.

What Happens During the Operation

Modern joint replacement is usually performed under spinal or general anaesthesia and lasts 90‑120minutes. The steps are:

1. Incision and exposure. The surgeon opens the joint capsule while protecting surrounding muscles and nerves.
2. Removal of damaged bone. Specialized saws and rasps excise the arthritic surfaces.
3. Trial components. Temporary prosthetic pieces are placed to assess fit, leg length, and range of motion.
4. Implant placement. Cemented or cement‑less stems are inserted; cementless designs rely on bone growth for long‑term stability.
5. Soft‑tissue balancing. Ligaments are tensioned to achieve a stable, pain‑free joint.
6. Closure. The capsule and skin are sutured, and a drain may be left for a few hours.

Because gouty tissue can be inflamed and friable, surgeons often use gentle retractors and may give a single intra‑operative dose of steroids to blunt the inflammatory response.

Recovery Timeline and Post‑operative Rehabilitation

After surgery you’ll move to a recovery room, then a short stay on the orthopaedic ward.

Day 0‑1: Pain is managed with a multimodal regimen-regional nerve block, low‑dose opioids, and NSAIDs (if kidney function allows). Early ambulation with a walker begins within 6‑12hours.

Day 2‑4: Physical therapist guides gentle hip/knee flexion, quadriceps sets, and ankle pumps. Most patients are discharged home by day three.

Weeks 2‑6: Outpatient PT focuses on gait training, strengthening, and range‑of‑motion milestones. Gout patients should continue urate‑lowering drugs throughout rehab.

Months 3‑6: Full weight‑bearing activities, low‑impact sports (swimming, cycling), and gradual return to work. Implant survival rates exceed 95% at ten years when serum uric acid remains controlled.

Post‑operative rehabilitation is a collaborative effort between the physiotherapist, orthopaedic team, and the patient’s rheumatologist to keep inflammation in check while rebuilding muscle strength.

Managing Pain, Gout Flares, and Long‑term Care

Even after a flawless surgery, gout doesn’t disappear. To protect the new joint:

• Maintain serum uric acid < 5mg/dL. Periodic blood tests every 3‑6 months are standard.
• Continue prophylactic colchicine or low‑dose steroids during the first 6 weeks post‑op, especially if you had frequent pre‑op flares.
• Stay hydrated (≥2L water daily) and limit high‑purine foods such as red meat, shellfish, and organ meats.
• Use ice packs on the joint for 15‑20minutes after PT sessions to reduce swelling.

Should a flare occur after the prosthesis is in place, treatment is similar to pre‑op management-NSAIDs (if renal function permits), colchicine, or a brief steroid burst-but always coordinate with the orthopaedic surgeon to rule out infection.

Risks Specific to Gouty Patients

All surgeries carry risk, but gout adds a few extra considerations:

Overall, the benefits of restored mobility and pain relief far outweigh these modest risks when uric acid is well‑controlled.

Bottom Line: Making the Decision

If gout has left a joint fused, deformed, or constantly painful, joint replacement can give you a new lease on life. The key to success lies in a coordinated care plan: keep uric acid low, optimise overall health, follow the surgeon’s rehab protocol, and stay vigilant for any flare‑ups.

Remember, surgery isn’t a cure for gout-it’s a solution for the damage the disease caused. Ongoing medication and lifestyle habits keep that damage from happening again.