Diabetic Neuropathic Arthropathy
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Review DIABETIC NEUROPATHIC ARTHROPATHY Ram Singh * Ashish Bhalla ** Atul Sachdev * S. S. Lehl * ABSTRACT nails along with proper selection of accommodative shoe wear (1). Table 1 shows the relationship Diabetic neuropathic arthropathy (Charcot's foot) is between duration of diabetes and the development being increasingly encountered in diabetic patients of neuropathic joint complications, as described by following their prolonged survival. It remains the Forgacs, in a study of 372 cases (4). On an average, foremost predisposing factor for foot amputation in over a two year period, the process can result in a diabetics. Other conditions associated with severely deformed foot, which is highly prone to Charcot's foot such as syphilis and syringomyelia ulcers, infection, and subsequent amputation (5). are rarely encountered. Early diagnosis, staging, Table 2 describes the commonly involved joints in preventive measures and the availability and utility diabetic neuroarthropathy (4). of newer imaging techniques is discussed. Conservative and early corrective surgical Tablel: Duration of Diabetes in Diabetic management techniques for stablization of this Osteoarthropathy (4). condition and prevention of amputation are emphasized. Duration of diabetes (years) Number of reported cases (%) 0-5 27(9.4) 6-10 50(7.5) KEY WORDS: Diabetic neuropathic arthropathy; 11-20 153(53.5) Charcot's foot; Staging; Imaging techniques; >21 56(19.6) Management. Total 286(100) INTRODUCTION Table 2: Localization of Diabetic Osteoarthropathy (4). Neuropathic arthropathy is a chronic, progressive Joints Number of reported cases (%) degenerative disorder affecting one or more Ankle 38 (10.2) Tarsus 81 (21.8) peripheral or vertebral articulations, which develops Tarsometatarsal joints 102 (27.4) as the result of a disturbance in the normal sensory Metatarsophalangeal joints 117 (31.5) (pain or proprioceptive) innervations of joints (1). Interphalangeal joints 34 (9.1) Charcot arthropathy is relatively rare, but an Total 372 (100) important and potentially devastating disorder (2). PATHOPHYSIOLOGY Diabetes mellitus, syphilis, and syringomyelia are the most commonly associated clinical entities. It Etiopathogenesis of foot disease in diabetes mellitus particularly affects patients with long-standing is multifactorial and results from a combination of diabetes, often with severe peripheral neuropathy in peripheral neuropathy, vascular compromise and both legs, together with features of autonomic superimposed infection. Foot complications in neuropathy, especially postural hypotension and diabetic patients are common and account for more gastroparesis. It presents with massive osseous hospital days, than any other aspect of their disease. destruction and malposition of the articular constituents (3). Peripheral vascular disease is Charcot process is poorly understood. Diabetic typically absent (2). neuropathy with reduced sensitivity to pain and mechanical overloading of the joints, associated When neuropathic arthropathy is suspected, careful with frequently disturbed circulation in the lower clinical evaluation should be performed to identify extremities are the etiopathogenetic factors involved the underlying neurological disorder (1). Within the in diabetic osteoarthropathy (synonyms: population of diabetic patients, it is widely accepted, neuroarthropathia diabetica, Charcotjoint)(6). It may that patients with neuropathic (Charcot) arthropathy be initiated by injury, often apparently trivial, which of the foot and ankle have the highest likelihood of may cause a minor periarticular fracture and having to undergo lower extremity amputation. The occasionally a major fracture. Charcot changes are current emphasis is on care of the foot, skin and more likely to develop in bones that have pre- * Reader, ** Senior Lecturer, Department of Medicine, Government Medical College and Hospital, Chandigarh. INT. J. DIAB. DEV. COUNTRIES (2000), VOL. 20 135 existing diabetic osteopenia, which in turn may be ulceration and infection, which can ultimately result related to increased blood flow in the neuropathic in loss of independent mobility, loss of the affected foot. Following the injury, osteoplastic activity is limb, and even death (8). A third of patients may stimulated, presumably in an attempt to remodel the however, have no demonstrable neurological deficit fractured bone. This persists, resulting in (7). destruction, fragmentation and finally remodelling. Acute Charcot arthropathy may be confused with INVESTIGATIONS local infection or inflammatory arthritis. Chronic Charcot foot is classically described as a bag of Diabetic patients with neuropathy had significantly bones (2). more radiographic abnormalities of the bones and joints than non-neuropathic and age-matched non Three stages in development of Charcot diabetic control subjects (9). Therefore, familiarity neuroarthropathy have been described. In the first with the spectrum of findings in the different stage there is osteonecrotic destruction of the bone imaging modalities appears essential. and cartilage. Clinically it has an insidious onset, is painless and a non-inflammatory hydroarthrosis, Early changes may be subtle and the characteristic with massive swelling of the soft tissues, is typical. changes are seen only in advanced cases. In In the second stage, there is irregular transformation problems concerning the diabetic foot, magnetic of the bone due to multiple resorptive processes. In resonance imaging, bone scans and leukocyte the third stage this transformation process stabilizes scintigraphy appear to be the most effective tools for and the bone ends become more pointed and more detection of osteomyelitis, and a negative study sclerotic (resembling a licked candy stick). For makes osteomyelitis unlikely. However, the mechanical reasons, the tarsometatarsal, osteoarthropathy may be indistinguishable from that metatarsophalangeal joints and the metatarsals are of acute osteomyelitis by these imaging modalities. primarily involved (6). Three-phase bone scans, particularly Technetium CLINICAL FEATURES scans (Tc99), demonstrate an early increase in bone uptake, which is due to the increase in blood flow Neuropathic arthritis is a destructive arthropathy through the bone that accompanies the active frequently associated with loss of proprioception. A Charcot process. It is a very sensitive test, but it also third of the patients, however, may have no detects infective and other inflammatory changes, demonstrable neurological deficit. Patients with and thus is not specific. It is important to diabetes mellitus, syphilis, syringomyelia and other differentiate Charcot arthropathy from infection, neuropathies are particularly prone to develop this particularly osteomyelitis. Indium labelled white joint disease. The diagnosis of Charcot's joints cells can be used to distinguish the two: a negative should be considered in anyone who develops what white-cell scan generally excludes infection, appears to be a severe osteoarthritis or a transverse although occasional false-negative results may be fracture of the tibia or fibula after a minor trauma. seen in immunosuppressed patients, who have low- Scoliosis with particularly destructive changes on grade osteomyelitis (2). radiography, should prompt a search for syringomyelia or syphilis (7). Magnetic resonance imaging shows bone destruction clearly. Recently, an open trial of the Diabetes mellitus is the leading cause of Charcot bisphosphonate, pamidronate (which inhibits neuroarthropathy. The most common location is osteoclast activity), was found to reduce swelling, along the medial column of the foot. Over a two local temperature and markers of bone turnover. year period, the process can result in a severely deformed foot, which is highly, prone to ulcers, STAGING infection, and subsequent amputation (5). To help identify the early stages of the disease Initial presentation is akin to an acutely inflamed process, history, physical examination and joint, which is usually associated with pain at the radiographs of the patients need to be evaluated. In a affected site. Later, warm, swollen joints, with a recent study, the authors were able to identify five grossly disorganized radiographic appearance stages of Charcot deformities (5). This can be a develop, inspite of which, the patient is often pain- useful guide for screening and managing patients of free. Neglect of this condition results in progressive Charcot's joint. deformity or instability, often complicated by INT. J. DIAB. DEV. COUNTRIES (2000), VOL. 20 136 Stage 0 is a clinical stage in which the patient In a retrospective, uncontrolled study by Boninger presents with locally swollen, warm, and often and Leonard, " Total contact, laminated, bivalved painful foot. Radiographs are negative and Tc99 ankle foot orthosis" (TCAFO) proved to be a safe, bone scan is markedly positive. Indium and gallium functional, and cost-effective therapy for scans are normal. complications of the neuropathic foot (10). Morgan and colleagues used CROW with success in 18 Stage 1 in addition to the clinical finding of a patients and found it to be a better method for painful swelling, X-rays of the affected joint prolonged immobilization and protection, necessary demonstrates periarticular cysts, erosions, localized for healing in neuropathic arthropathy (11). osteopenia, and sometimes diastases. ROLE OF SURGERY Stage 2 is marked by painless joint swelling with X- rays showing joint subluxations, usually starting Surgery