Charcot joint / Neuropathic Joint

Charcot joint or neuropathic joint are destructed joint occurs in Diabetes, syphilis, syringomyelia , leprosy, AMLS, Peripheral neuropathy and any condition leads to impair sensation of peripheral part of body

1. CHARCOT JOINT by Dr Maulik T Patel

2. 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.

3. 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%

4. Pathophysiology NEUROTRAUMATIC THEORY; An unperceived trauma or injury to an insensate joint. NEUROVASCULAR THEORY: autonomic neuropathy increase vascularity mismatch in destruction & synthesis

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

6. 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

7. 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

8. AP radiography shows fragmentation and joint destruction .

9. AP radiograph shows joint destruction and dislocation.

10. Elbow    syringomyelia syphilis congenital insensitivity to pain diabetes Charcot-Marie-Tooth

11. AP radiograph shows joint destruction and heterotrophic ossificans .

12. X rays showing joint destruction and dislocation

13. X rays shows joint destruction and new bone formation

14. 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

15. Stage 0 Hot foot X rays normal MRI shows marrow edema and micro fractures

16. Stage 1 ( Hydrarthrosis ) Fragmentation Bone resorption Fracture dislocation

17. Stage 2 ( Atrophy) Coalescence Sclerosis Fracture healing Debris resorption

18. Stage 3 ( Hypertrophy) Remodeling

19. 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

20. 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

21. 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

22. 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)

23. 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

24. 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

25. 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

26. An ounce of prevention is worth a pound of cure.” – Benjamin Franklin