Updated: 12/27/2021

Neuropathic (Charcot) Arthropathy

Review Topic
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  • Snapshot
    • A 62-year-old woman presents to her physician for painless swelling of her ankle. She reports a history of diabetic neuropathy and regularly sees a podiatrist. Physical exam reveals a non-tender, swollen, and erythematous ankle joint with decreased range of motion. Laboratory studies show a normal leukocyte count and normal inflammatory markers.
  • Introduction
    • Clinical definition
      • arthropathy due to underlying neuropathy or trauma, leading to a destruction of joints and bone
  • Epidemiology
    • demographics
      • adults
    • location
      • foot and ankle (most common)
      • shoulder
      • elbows
    • risk factors
      • diabetic neuropathy
        • for foot and ankle disease
      • syringomyelia
        • for shoulder disease
      • syphilis
        • for knee disease
      • trauma
      • leprosy
  • Etiology
    • Pathogenesis
      • autonomic neuropathy can result in hyperemia, which leads to increased osteoclastic resorption of the bone
      • peripheral neuropathy can result in loss of sensation and proprioception, which leads to unintentional repetitive trauma and injury
      • subsequent new bone formation and healing results in deformation of joints
    • Associated conditions
      • diabetes mellitus
      • tertiary syphilis
        • tabes dorsalis
      • chronic alcohol misuse disorder
      • syringomyelia
      • myelomeningocele
      • spinal cord tumors
      • subacute combined degeneration (vitamin B12 deficiency)
  • Presentation
    • Symptoms
      • non-painful swelling of a joint
    • Physical exam
      • acutely, may present as non-tender, erythematous, edematous, and warm joint
      • chronically, may present as joint or foot deformity with joint effusion and bony prominences
        • most common deformity is a collapse of the tarsometatarsal joint, with valgus angulation
      • may find other signs of chronic neuropathy, including foot ulcers
        • decreased or absent vibration sensation
        • loss of deep tendon reflexes
  • Imaging
    • Radiography
      • indication
        • for all patients
      • findings
        • can be normal in early Charcot joint
        • acute
          • bony consolidation with fractures, joint effusion, or bone destruction
        • chronic
          • bony deformity, new bone formation, and sclerosis
          • resorption of bone
    • Magnetic resonance imaging (MRI) with gadolinium
      • indication
        • if radiograph is unclear and if osteomyelitis is suspected
      • finding
        • osseous edema
    • Bone scintigraphy (typically, technetium-99m-labeled methylene diphosphonate followed by indium-labeled leukocyte scintigraphy)
      • indication
        • to further distinguish neuropathic arthropathy from osteomyelitis
      • findings
        • negative (cold) for neuropathic arthropathy
        • positive (hot) for osteomyelitis
  • Studies
    • Labs
      • typically, normal white blood cell count and markers of inflammation (erythrocyte sedimentation rate and C-reactive protein)
    • Making the diagnosis
      • based on clinical presentation and imaging
  • Differential
    • Cellulitis
      • distinguishing factor
        • no bony deformities or changes on imaging
    • Osteomyelitis
      • distinguishing factor
        • increased inflammatory markers
        • MRI and bone scintigraphy findings of osteomyelitis
  • Treatment
    • Conservative
      • immobilization and rest
        • indication
          • for all patients, especially in the acute phase
      • accommodative footwear
        • indication
          • for all patients, especially in the chronic phase
    • Operative
      • surgical repair
        • indications
          • only recommended for severe deformities
          • not usually performed
  • Complications
    • Spontaneous fractures
    • Osteomyelitis
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