CHARCOT JOINTby

Dr Maulik T Patel

In 1868, Jean-Martin Charcot gave the first detailed description of the neuropathic aspect of this disease; hence, the condition is named after him.

Progressive destructive disease of joint.

Painless arthropathy with dislocation, fracture, debilited deformities.

Frequently misdiagnosed.

Most commonly involve joints of lower limb.

Any condition that causes sensory or autonomic neuropathy can lead to a Charcot joint

Diabetes is considered to be the most common cause of Charcot arthropathy.

Prevalence is 0.5%.

Bilateral disease in < 10%

Pathophysiology

NEUROTRAUMATIC THEORY; An unperceived trauma or injury to an

insensate joint.

NEUROVASCULAR THEORY: autonomic neuropathy increase

vascularity mismatch in destruction & synthesis

Genetics molecular biology RANK/RANKL/OPG triad pathway is thought to be

involved 

Associated conditions shoulder  syringomyelia  

most common etiology of neuropathic arthropathy of the upper extremity 

25% of these patients develop a neuropathic joint Mono articular (shoulder > elbow)

Hansen's disease (leprosy) second most common cause of upper extremity

neuropathic arthropathy

syphilis usually affects the knee can be poly articular

diabetes most common cause of foot and ankle neuropathic

joints

Arnold- Chiari malformation cervical spondylosis adhesive arachnoiditis and TB arachnoiditis posttraumatic syringomyelia alcoholism

AP radiography shows fragmentation and joint destruction.

AP radiograph shows joint destruction and dislocation.

Elbow  

syringomyelia syphilis congenital insensitivity to pain diabetes Charcot-Marie-Tooth

AP radiograph shows joint destruction and heterotrophic ossificans.

X rays showing joint destruction and dislocation

X rays shows joint destruction and new bone formation

Classification Eichenholtz Classification

Stage 0 • Joint edema • Radiographs are negative • Bone scan may be positive in all stages

Stage 1 • Joint edema • Radiographs show osseous fragmentation with joint dislocation 

Stage 2 • Decreased local edema • Radiographs show coalescence of fragments and absorption of fine bone debris

Stage 3 • No local edema • Radiographs show consolidation and remodeling of fracture fragments

Stage 0 Hot foot X rays normal MRI shows

marrow edema and micro fractures

Stage 1 (Hydrarthrosis)

Fragmentation Bone resorption Fracture dislocation

Stage 2 ( Atrophy)

Coalescence Sclerosis Fracture healing Debris resorption

Stage 3( Hypertrophy) Remodeling

Presentation Symptoms swollen shoulder or elbow  50% have pain, 50% are painless loss of function

Physical exam inspection

swollen, warm, erythematous joint mimics infection

motion joint may be mechanically unstable loss of active motion, but passive motion is maintained

neurovascular a neurologic evaluation is essential

Imaging Radiographs recommended views

standard views of affected joint AP and scapula Y of the shoulder AP and lateral of the elbow AP and lateral of foot and ankle

findings early changes

degenerative changes may mimic osteoarthritis late changes

obliteration of joint space fragmentation of both articular surfaces of a joint leading

to subluxation or dislocation scattered "chunks" of bone in fibrous tissue joint distention by fluid surrounding soft tissue edema heterotopic ossification fracture

MRI indications

MRI of cervical spine to rule out syrinx when neuropathic shoulder arthropathy is present  

Bone scan technetium bone scan

findings may be positive (hot) for neuropathic joints and

osteomyelitis indium WBC scan

findings will be negative (cold) for neuropathic joints and positive

(hot) for osteomyelitis useful to differentiate from osteomyelitis

Studies Labs

ESR and WBC can be elevated making it difficult to differentiate from osteomyelitis

Histology synovial hypertrophy detritic synovitis (cartilage and bone distributed in

synovium)

Differential diagnosis :

Osteomyelitis/septic joint difficult to distinguish from osteomyelitis based on

radiographs and physical exam common findings in both conditions

swelling, warmth elevated WBC and ESR technetium bone scan is "hot"

unique to Charcot joint disease indium leukocyte scan will be "cold" (negative)

will be "hot" (positive) for osteomyelitis

Treatment Non operative

rest, elevation, protected immobilization with a sling, and restriction of activity indications

neuropathic shoulder joint functional bracing

indications neuropathic elbow joint

technique should allow flexion-extension, but neutralizes varus-

valgus stresses

Operative

Arthrodesis do not attempt during acute inflammatory stage

(Eichenholtz 0-2) because of continued bone erosion only perform during quiescent stage (Eichenholtz 3)

requires long periods of immobilization

Total joint replacement indications

 Charcot joint is a contraindication to total joint replacement due to poor bone stock, prosthetic loosening, instability,

and soft-tissue compromise

An ounce of prevention is worth a pound of cure.”

– Benjamin Franklin