Charcot Joint  neuropathic joint disease,  neuroarthropathy,  Charcot joint disease,  neuropathic osteoarthropathy,

Charcot Joint ( definition)  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.

Pathophysiology:  the loss of proprioception and deep sensation leads to recurrent trauma, which ultimately leads to progressive destruction, degeneration, and disorganization of the joint.(neurotraumatic) (German)  Another theory neurally mediated vascular reflex results in hyperemia, which can cause osteoclastic bone resorption.(neurovascular) (French) 

Clinical Details  The affected joint is usually swollen and warm and does not cause pain  Pain may be noted at presentation in one third of patients,  but the response to deep pain and proprioception may be reduced.

Causes of neuropathic arthropathy  Diabetes  Use of steroids  Alcoholism  Trauma  Amyloidosis  Pernicious anemia  Syphilis  Syringomyelia  Spina bifida  Myelomeningocele  Leprosy  Multiple sclerosis  Charcot-Marie-Tooth disease  Cord compression  Asymbolia  Ehlers-Danlos syndrome  Adrenal hypercorticism  Thalidomide (embryopathy)  Paraneoplastic sensory neuropathy  Cauda equina lipoma

incidence  in 15% of patients with diabetes  in 10-20% of patients with tabes dorsalis  in 20-25% of patients with syringomyelia.

Diabet  metatarsophalangeal  tarsometatarsal  intertarsal joints

Diabet

Normal foot

Fracture In diabet patient

intertarsal joints

Normal foot

Rocker bottom

Charcot Neuroarthropathy Clinical Presentation  Rocker bottom foot

Syringomyelia  shoulder joint, followed by the elbow and wrist.  Changes in the spine are most characteristic in the cervical region.  The lower extremities can also be 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

asymbolia ( congenital insensitivity to pain )  ankle and intertarsal joints

Asymbolia (intertarsal joints)

Insensetive to pain

tabes dorsalis  The joints of the lower extremity ( knee, ankle)  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:

Tabes dorsalis (Ankle)

suspicion of Charcot joint  Progressive joint effusion  fracture  fragmentation  subluxation

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

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

 Narrowing of the joint space joint space

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

Fragmentation

Intra-articular loose bodies (bag of bones

Bag of Bone

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

Metatarsal fracture( Lisfranc fracture/dislocation )

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

 Soft tissue calcification  deformity, and dislocation.

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

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

Rapid bone resorption

Ultrasound  Ultrasonography has no role in the diagnosis of neuropathic arthropathy.  Ultrasonography can be used to identify any local collection when an infection occurs, and it can be used to guide aspiration for obtaining cytologic specimens.

MRI.  MRI plays a significant role in diagnosing complications  involved joints appear diffusely swollen and demonstrate low signal intensity.  In general, bone marrow edema found close to a skin ulceration and away from a joint suggests infection.

MRI

Nuclear Scan  Increased uptake on radioisotope scan is seen in both neuropathic joints and in infection.  Three-phase bone scan and 67Ga scintigraphy are sensitive but not specific.  Imaging using 111In–labeled leukocytes has the sensitivity (87%) and specificity (81%) for detecting osteomyelitis in a neuropathic foot.

CT SCAN  CT has no significant role in the diagnosis of neuropathic arthropathy.  CT may be helpful in evaluating cortical destruction, sequestra, and intraosseous gas.

Differentiated diagnosis  Osteoarthritis  Calcium pyrophosphate dihydrate crystal deposition disease deposition disease  Osteonecrosis  Posttraumatic osteoarthritis  Infection  DVT

Treatment  No specific therapy  Joint immobilization ( Cast, brace, orthotics)  Restricted weight bearing  Control of blood glucose  Amitryptyline & Biphosphonate  Arthrodesis  Exostomy  Total joint replacement  amputation