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Neuropathic (Charcot) Arthropathy

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Neuropathic (Charcot) Arthropathy Neuropathic (Charcot) Arthropathy Disturbance in sensation leads to multiple microfractures o Pain sensation is intact from muscles and soft tissue Distribution and causes o Shoulders – syrinx, spinal tumor o Hips – tertiary syphilis, diabetes o Knees – tertiary syphilis (more bone production), diabetes (less bone production) o Feet – diabetes o Other causes . Amyloidosis . Congenital indifference to pain . Polio . Alcoholism X-ray findings o Sclerosis o Destruction of joint o Fragmentation o Soft tissue swelling from synovitis o Joint effusions o Osteophytosis o Disorganized and disrupted joint o No osteoporosis Marked sclerosis, fragmentation and joint destruction are the hallmarks of a neuropathic joint here cause by tabes DDX o Degenerative joint disease . Eventually neuropathic joint shows more sclerosis . More fragmentation in neuropathic . More destruction of bone in neuropathic o CPPD . Associated with chondrocalcinosis which a neuropathic joint is not Neuropathic (Charcot) Arthropathy General Considerations Most commonly caused by diabetes today Bilaterally is rare in foot Disturbance in sensation leads to multiple microfractures o Pain sensation is intact from muscles and soft tissue Distribution and causes o Shoulders – syringomyelia, spinal tumor o Elbows and wrists -- syringomyelia o Hips – tertiary syphilis, diabetes o Knees – tertiary syphilis (more bone production), diabetes (less bone production) o Feet – diabetes, congenital insensitivity to pain, chronic alcoholism o Other causes . Leprosy . Amyloidosis – knee and ankle . Congenital indifference to pain . Polio . Alcoholism Clinical Findings Signs of inflammation in acute phase Swelling is very common Pain can occur in 75% of cases but is usually less severe than would be expected on the basis of the radiologic findings Instability Loss of joint function May produce a mass at the joint because of swelling Imaging Findings Conventional radiography is usually sufficient to make the diagnosis Findings include: o Sclerosis from eburnation of subchondral bone o Destruction of joint o Fragmentation o Subluxation and dislocation o Soft tissue swelling from synovitis may be massive o Joint effusions o Osteophytosis o Disorganized and disrupted joint o No osteoporosis Differential Diagnosis Degenerative joint disease o Especially in early stages o Eventually neuropathic joint shows more sclerosis o More fragmentation in neuropathic o More destruction of bone in neuropathic Calcium Pyrophosphate Deposition Disease o Associated with chondrocalcinosis which a neuropathic joint is not o Also more fragmentation in neuropathic joint Osteomyelitis o MRI and nuclear medicine scans, including FDG-PET scans, may help in differentiation Treatment Usually non-operative Surgery if unstable, nonreducible fractures or dislocations Neuropathic arthropathy (Charcot joint) can be defined as bone and joint changes that occur secondary to loss of sensation and that accompany a variety of disorders. Charcot first described the relationship between loss of sensation and arthropathy in 1868. The radiographic changes of this condition include destruction of articular surfaces, opaque subchondral bones, joint debris, deformity, and dislocation (see the images below). Neuropathic arthropathy (Charcot joint) poses a special problem in imaging when it is associated with a soft-tissue infection.[1, 2, 3, 4, 5, 6, 7] Neuropathic arthropathy (Charcot joint). Neuropathic arthropathy of the shoulder in a patient with syringomyelia. Note the destruction of the articular surface, dislocation, and debris, which are pathognomonic for a neuropathic joint. Neuropathic arthropathy (Charcot joint). Osteolysis of the distal metatarsals and phalanges with tapering results in a pencil-like appearance in the late stage of diabetic neuropathy. Leprosy is one of many causes of neuropathic arthropathy (Charcot joint); joint manifestations of this disease include signs of Charcot disease, which advances despite treatment.[8] Neuropathic arthropathy related to diabetes, syphilis, leprosy, and connective tissue disorders is more common in the elderly population. Neuroarthropathy related to asymbolia, spina bifida, and spinal trauma is more common in young individuals. Sensory impairment associated with spina bifida and myelomeningocele is the most frequent cause of neuropathic arthropathy (Charcot joint) in childhood. Neuropathic arthropathy can be classified into hypertrophic and atrophic types. Hypertrophic changes predominate in the upper motor neuron lesions, and atrophic changes occur in peripheral nerve injuries. The early stage ofosteoarthritis simulates neuropathic arthropathy (Charcot joint), both radiologically and pathologically. Progressive joint effusion, fracture, fragmentation, and subluxation should raise the suspicion of neuroarthropathy. In the advanced stage, abnormal findings on radiographs include subchondral sclerosis, osteophytosis, subluxation, and soft-tissue swelling. Long-standing neuroarthropathy is characterized by disorganization of joints. The finding of considerable amounts of cartilaginous and osseous debris within the synovial membrane (termed detritic synovitis) should alert the pathologist that the changes may represent a neuropathic joint. Other causes of detritic synovitis include osteonecrosis, calcium pyrophosphate dihydrate crystal deposition disease, psoriatic arthritis, osteoarthritis, and osteolysis with detritic synovitis. Preferred examination Radiography may be the only imaging required for the diagnosis of neuropathic arthropathy (Charcot joint). In the appropriate clinical setting, a fairly accurate diagnosis can be achieved. The roles of ultrasonography and computed tomography (CT) scanning are limited; however, these 2 modalities can be helpful in identifying any local collection, and they can be used to guide aspiration cytology. The role of magnetic resonance imaging (MRI) and radionuclide scanning is to differentiate soft-tissue infection from osteomyelitis.[9, 10] Limitation of techniques Radiographic findings in the early stages of neuropathic arthropathy (Charcot joint) may simulate osteoarthritis. Radiographs may not demonstrate findings that help in diagnosing osteomyelitis in neuropathic joints, which is a common problem. The roles of ultrasonography and CT scanning are limited. Ultrasonography can be used to identify any local collection when infection occurs and to guide aspiration for cytologic analysis; however, it provides no further information regarding the integrity of underlying bone. Although CT scanning may be helpful in evaluating cortical destruction, sequestra, and intraosseous gas, these changes are not specific for neuropathic arthropathy. The role of MRI and radionuclide scanning is to differentiate soft-tissue infection from osteomyelitis. Bone marrow edema is nonspecific and has several causes; therefore, differentiating bone marrow edema from neuropathic arthropathy (Charcot joint) may not be possible on the basis of MRI findings alone. Similarly, enhanced bone activity on radionuclide scans is a nonspecific finding and may occur with several neoplastic, inflammatory, and degenerative processes. Differential diagnosis and other problems to be considered Calcium pyrophosphate deposition disease and primary osteoarthritis are in the differential diagnosis. In addition, in the early stage, neuropathic arthropathy (Charcot joint) can simulate osteoarthritis, and bone fragmentation and collapse are seen in osteonecrosis, posttraumatic osteoarthritis, intra- articular steroid injection, infection, and alkaptonuria. Baker et al reviewed neuropathic arthropathy in diabetics.[11] Neuropathic diabetic arthropathy, particularly in the feet, is the leading cause of morbidity in diabetic patients. It has many mimics. Ulcers, sinus tracts, or an abscess with an adjacent region of abnormal signal intensity in bone marrow suggests osteomyelitis. Contrast-enhanced MRI allows differentiation of viable tissue from necrotic regions in diabetic foot infections, which require surgical debridement in addition to antibiotic therapy. Subtraction images are particularly useful for visualizing nonviable tissue. Dialysis-associated spondyloarthropathy occurs in diabetic patients with a long history of hemodialysis. Intervertebral disk space narrowing without T2 signal hyperintensity, extensive endplate erosions without endplate remodelling, and facet joint involvement are suggestive of spondyloarthropathy instead of infectious diskitis or degenerative disk disease. The clinical features of infective diskitis and spondyloarthropathy overlap, but knowledge of the patient's medical history, and recognition of imaging characteristics described above allows the radiologist to make a prompt and accurate diagnosis, leading to prompt appropriate treatment.[11] Special concerns The incidence of osteomyelitis is increased in patients with neuropathic joints, particularly in the foot. Hence, careful follow-up imaging is essential. CHARCOT’S FOOT Figure 1: X-ray of the feet showing Figure 2: Annotated x-ray of the feet Charcot's joint deformity. showing Charcot's joint deformity. (Click on image to enlarge) (Click on image to enlarge) A Charcot joint (neuropathic joint) is due to a progressive destructive joint disorder in patients with impaired pain sensation and proprioception. In contemporary medicine, particularly when involving the foot/ankle, this is due to longstanding diabetes. The 2 theories for the pathophysiology of this condition are the
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