Charcot JointCharcot Joint

neuropathic joint disease,neuropathic joint disease, neuroarthropathy,neuroarthropathy, Charcot joint disease, Charcot joint disease, neuropathic osteoarthropathy,neuropathic osteoarthropathy,

Charcot Joint ( definition)Charcot Joint ( definition)

defined as bone and joint changes that defined as bone and joint changes that occur secondary to occur secondary to loss of sensationloss of sensation and and that accompany a variety of disorders. that accompany a variety of disorders.

Charcot first described the relationship Charcot first described the relationship between loss of sensation and between loss of sensation and arthropathy in 1868. arthropathy in 1868.

Pathophysiology: Pathophysiology:

the loss of the loss of proprioceptionproprioception and and deep sensation deep sensation leads toleads to recurrent trauma recurrent trauma, which ultimately , which ultimately leads to progressive destruction, degeneration, leads to progressive destruction, degeneration, and disorganization of the joint.and disorganization of the joint.((neurotraumaticneurotraumatic) (German)) (German)

Another theory neurally mediated Another theory neurally mediated vascular reflex results in hyperemia, which can vascular reflex results in hyperemia, which can cause cause osteoclasticosteoclastic bone resorption . bone resorption .((neurovascularneurovascular) (French)) (French)

Clinical Details Clinical Details

The affected joint is usuallyThe affected joint is usually swollen swollen and and warmwarm and does not cause pain and does not cause pain

Pain Pain may be noted at presentation in may be noted at presentation in one third of patients,one third of patients,

but the response to but the response to deep paindeep pain and and proprioceptionproprioception may be reduced. may be reduced.

Causes of neuropathic Causes of neuropathic arthropathy arthropathy

Diabetes Diabetes Use of steroids Use of steroids Alcoholism Alcoholism Trauma Trauma Amyloidosis Amyloidosis Pernicious anemia Pernicious anemia Syphilis Syphilis Syringomyelia Syringomyelia Spina bifida Spina bifida Myelomeningocele Myelomeningocele Leprosy Leprosy Multiple sclerosis Multiple sclerosis

Charcot-Marie-Tooth Charcot-Marie-Tooth disease disease

Cord compression Cord compression Asymbolia Asymbolia Ehlers-Danlos syndrome Ehlers-Danlos syndrome Adrenal hypercorticism Adrenal hypercorticism Thalidomide Thalidomide

(embryopathy) (embryopathy) Paraneoplastic sensory Paraneoplastic sensory

neuropathy neuropathy Cauda equina lipoma Cauda equina lipoma

incidence incidence

in 15% of patients with diabetes in 15% of patients with diabetes in 10-20% of patients with tabes in 10-20% of patients with tabes

dorsalisdorsalis in 20-25% of patients with in 20-25% of patients with

syringomyelia. syringomyelia.

DiabetDiabet

metatarsophalangealmetatarsophalangeal tarsometatarsaltarsometatarsal intertarsal jointsintertarsal joints

DiabetDiabet

Normal footNormal foot

Fracture In diabet patient Fracture In diabet patient

intertarsal jointsintertarsal joints

Normal footNormal foot

Rocker bottom Rocker bottom

Charcot NeuroarthropathyCharcot Neuroarthropathy

Clinical PresentationClinical Presentation

Rocker bottom footRocker bottom foot

SyringomyeliaSyringomyelia

shoulder jointshoulder joint, followed by the , followed by the elbowelbow and and wrist.wrist.

Changes in the spine are most Changes in the spine are most characteristic in the cervical region. characteristic in the cervical region.

The lower extremities can also be The lower extremities can also be affected in syringomyelia. affected in syringomyelia.

Clinical images: Syrinx-induced Charcot shoulder Arthritis & RheumatismVolume 50, Issue 7, Date: July 2004, Pages: 2380

Khan et al. Neuropathic Arthropathy. EMedicine.com. Feb 2003

asymboliaasymbolia ((congenital insensitivity to paincongenital insensitivity to pain))

ankle and intertarsal jointsankle and intertarsal joints

AsymboliaAsymbolia(intertarsal joints)(intertarsal joints)

Insensetive to painInsensetive to pain

tabes dorsalistabes dorsalis

The joints of the lower extremity The joints of the lower extremity ( ( kneeknee,, ankle ankle))

Other sites include :Other sites include :

forefoot forefoot

midfoot midfoot

vertebral column.vertebral column.

Kapila A, Lines M. Neuropathic spinal arthropathy: CT and MR findings. J Comput Assist Tomogr 1987; 11:736-739

Tabes dorsalisTabes dorsalis (Ankle) (Ankle)

suspicion of Charcot jointsuspicion of Charcot joint

Progressive joint effusionProgressive joint effusion fracturefracture fragmentationfragmentation subluxation subluxation

detritic synovitis detritic synovitis

The finding of considerable amounts The finding of considerable amounts of of cartilaginouscartilaginous and and osseous debris osseous debris within the synovial membrane within the synovial membrane (termed detritic synovitis)(termed detritic synovitis)

The radiographic changes The radiographic changes Narrowing of the joint spaceNarrowing of the joint space Fragmentation of eburnated subchondral bone Fragmentation of eburnated subchondral bone

and loose bodies (bag of bones)and loose bodies (bag of bones) Lisfranc fracture Lisfranc fracture Soft tissue calcificationSoft tissue calcification deformity, and dislocation. deformity, and dislocation. Rapid bone resorption demonstrating pencil-in-Rapid bone resorption demonstrating pencil-in-

a-cup deformity a-cup deformity

Narrowing of the Narrowing of the joint spacejoint space

The radiographic changes The radiographic changes Narrowing of the joint spaceNarrowing of the joint space Fragmentation of eburnated subchondral boneFragmentation of eburnated subchondral bone and loose bodies (bag of bones)and loose bodies (bag of bones) Lisfranc fractureLisfranc fracture Soft tissue calcificationSoft tissue calcification deformity, and dislocation. deformity, and dislocation. Rapid bone resorption demonstrating pencil-in-Rapid bone resorption demonstrating pencil-in-

a-cup deformity a-cup deformity

FragmentationFragmentation

Intra-articular loose bodies (bag of bonesIntra-articular loose bodies (bag of bones

Bag of BoneBag of Bone

The radiographic changes The radiographic changes Narrowing of the joint spaceNarrowing of the joint space Fragmentation of eburnated subchondral boneFragmentation of eburnated subchondral bone and loose bodies (bag of bones)and loose bodies (bag of bones) Lisfranc fracture Lisfranc fracture Soft tissue calcificationSoft tissue calcification deformity, and dislocation. deformity, and dislocation. Rapid bone resorption demonstrating pencil-in-Rapid bone resorption demonstrating pencil-in-

a-cup deformity a-cup deformity

Metatarsal fracture( Lisfranc fracture/dislocation )Metatarsal fracture( Lisfranc fracture/dislocation )

The radiographic changes The radiographic changes Narrowing of the joint spaceNarrowing of the joint space Fragmentation of eburnated subchondral boneFragmentation of eburnated subchondral bone and loose bodies (bag of bones)and loose bodies (bag of bones) Lisfranc fracture Lisfranc fracture Soft tissue calcificationSoft tissue calcification deformity, and dislocation. deformity, and dislocation. Rapid bone resorption demonstrating pencil-in-Rapid bone resorption demonstrating pencil-in-

a-cup deformity a-cup deformity

Soft tissue calcificationSoft tissue calcificationdeformity, and deformity, and dislocation. dislocation.

The radiographic changes The radiographic changes Narrowing of the joint spaceNarrowing of the joint space Fragmentation of eburnated subchondral boneFragmentation of eburnated subchondral bone and loose bodies (bag of bones)and loose bodies (bag of bones) Lisfranc fracture Lisfranc fracture Soft tissue calcificationSoft tissue calcification deformity, and dislocation. deformity, and dislocation. Rapid bone resorption demonstrating pencil-in-Rapid bone resorption demonstrating pencil-in-

a-cup deformity a-cup deformity

The radiographic changes The radiographic changes Narrowing of the joint spaceNarrowing of the joint space Fragmentation of eburnated subchondral boneFragmentation of eburnated subchondral bone and loose bodies (bag of bones)and loose bodies (bag of bones) Lisfranc fractureLisfranc fracture Soft tissue calcificationSoft tissue calcification deformity, and dislocation. deformity, and dislocation. Rapid bone resorptionRapid bone resorption demonstrating pencil-in- demonstrating pencil-in-

a-cup deformity a-cup deformity

Rapid bone resorptionRapid bone resorption

UltrasoundUltrasound

Ultrasonography has no role in the Ultrasonography has no role in the diagnosis of neuropathic arthropathy.diagnosis of neuropathic arthropathy.

Ultrasonography can be used to identify Ultrasonography can be used to identify any any local collectionlocal collection when an infection when an infection occurs, and it can be used to occurs, and it can be used to guide guide aspiration for obtaining cytologic aspiration for obtaining cytologic specimens. specimens.

MRIMRI . . MRI plays a MRI plays a significant rolesignificant role in diagnosing in diagnosing

complicationscomplications

involved joints appear diffusely swollen and involved joints appear diffusely swollen and demonstrate low signal intensity.demonstrate low signal intensity.

In general, bone marrow edema found close to a In general, bone marrow edema found close to a skin ulceration and away from a joint suggests skin ulceration and away from a joint suggests infection. infection.

MRIMRI

Nuclear Scan Nuclear Scan Increased uptake on radioisotope scan is seen in Increased uptake on radioisotope scan is seen in

both neuropathic joints and in infection. both neuropathic joints and in infection. Three-phase bone scan and Three-phase bone scan and 67Ga67Ga scintigraphy scintigraphy

are sensitive but not specific. are sensitive but not specific. Imaging using 111In–labeled leukocytesImaging using 111In–labeled leukocytes has the has the

sensitivity (87%) and specificity (81%) for sensitivity (87%) and specificity (81%) for detecting detecting osteomyelitisosteomyelitis in a neuropathic foot. in a neuropathic foot.

CT SCAN CT SCAN

CT has CT has no significant roleno significant role in the in the diagnosis of neuropathic arthropathy.diagnosis of neuropathic arthropathy.

CT may be helpful in evaluating cortical CT may be helpful in evaluating cortical destruction, sequestra, and intraosseous destruction, sequestra, and intraosseous gas. gas.

Differentiated diagnosisDifferentiated diagnosis

OsteoarthritisOsteoarthritis Calcium pyrophosphate dihydrate crystal Calcium pyrophosphate dihydrate crystal deposition diseasedeposition disease OsteonecrosisOsteonecrosis Posttraumatic osteoarthritisPosttraumatic osteoarthritis InfectionInfection DVTDVT

TreatmentTreatment No specific therapyNo specific therapy Joint immobilization ( Cast , brace, orthotics)Joint immobilization ( Cast , brace, orthotics) Restricted weight bearingRestricted weight bearing Control of blood glucoseControl of blood glucose Amitryptyline & BiphosphonateAmitryptyline & Biphosphonate ArthrodesisArthrodesis ExostomyExostomy Total joint replacementTotal joint replacement amputationamputation