Diabetic neuropathic arthropathy
- Lesley D Hordon, MD
Lesley D Hordon, MD
- Consultant in Rheumatology
- University of Leeds, United Kingdom
- Section Editors
- Simon M Helfgott, MD
Simon M Helfgott, MD
- Associate Professor of Medicine
- Harvard Medical School
- David M Nathan, MD
David M Nathan, MD
- Editor-in-Chief — Endocrinology
- Section Editor — Diabetes Mellitus
- Professor of Medicine
- Harvard Medical School
In patients with diabetes mellitus, the loss of sensation to a joint may result in a chronic, progressive, and destructive arthropathy. The prototype of this disorder was described by Charcot in relation to tabes dorsalis. Similar changes are seen with other neurologic disorders, such as syringomyelia, although diabetes is the most common cause of neuropathic (Charcot) arthropathy in the western world. Diabetic neuropathic arthropathy is also called diabetic osteoarthropathy.
A variety of other musculoskeletal conditions have also been associated with diabetes mellitus, including specific arthropathies of the hand and shoulder, limited joint mobility, and spontaneous infarction of skeletal muscle.
Diabetic neuropathic arthropathy will be reviewed here. Other musculoskeletal conditions associated with diabetes, limited joint mobility in diabetes, and diabetic muscle infarction are described separately. (See "Musculoskeletal complications in diabetes mellitus" and "Diabetic muscle infarction" and "Limited joint mobility in diabetes mellitus".)
The pathogenesis of this condition remains uncertain; it is likely to be multifactorial, due to a combination of mechanical and vascular factors resulting from diabetic peripheral and autonomic neuropathy and metabolic abnormalities of bone (algorithm 1) [1-4].
It is thought that lack of proprioception secondary to peripheral neuropathy may result in ligamentous laxity, increased range of joint movement, instability, and damage by minor trauma, to which the relatively insensitive neuropathic foot is prone. In addition, the resulting change in the architecture of the foot causes a change in weightbearing and subsequent localized trauma. Finally, autonomic neuropathy may result in vasomotor changes and in the formation of arteriovenous shunts. These, in turn, result in reductions in effective skin and bone blood flow, despite the good and sometimes bounding foot pulses in these patients.
- Giurini JM, Chrzan JS, Gibbons GW, Habershaw GM. Charcot's disease in diabetic patients. Correct diagnosis can prevent progressive deformity. Postgrad Med 1991; 89:163.
- Brower AC, Allman RM. Pathogenesis of the neurotrophic joint: neurotraumatic vs. neurovascular. Radiology 1981; 139:349.
- Sinha S, Munichoodappa CS, Kozak GP. Neuro-arthropathy (Charcot joints) in diabetes mellitus (clinical study of 101 cases). Medicine (Baltimore) 1972; 51:191.
- Jeffcoate WJ, Game F, Cavanagh PR. The role of proinflammatory cytokines in the cause of neuropathic osteoarthropathy (acute Charcot foot) in diabetes. Lancet 2005; 366:2058.
- Baumhauer JF, O'Keefe RJ, Schon LC, Pinzur MS. Cytokine-induced osteoclastic bone resorption in charcot arthropathy: an immunohistochemical study. Foot Ankle Int 2006; 27:797.
- Mabilleau G, Petrova NL, Edmonds ME, Sabokbar A. Increased osteoclastic activity in acute Charcot's osteoarthropathy: the role of receptor activator of nuclear factor-kappaB ligand. Diabetologia 2008; 51:1035.
- Petrova NL, Dew TK, Musto RL, et al. Inflammatory and bone turnover markers in a cross-sectional and prospective study of acute Charcot osteoarthropathy. Diabet Med 2015; 32:267.
- Sequeira W. The neuropathic joint. Clin Exp Rheumatol 1994; 12:325.
- Fabrin J, Larsen K, Holstein PE. Long-term follow-up in diabetic Charcot feet with spontaneous onset. Diabetes Care 2000; 23:796.
- Petrova NL, Foster AV, Edmonds ME. Difference in presentation of charcot osteoarthropathy in type 1 compared with type 2 diabetes. Diabetes Care 2004; 27:1235.
- Stuck RM, Sohn MW, Budiman-Mak E, et al. Charcot arthropathy risk elevation in the obese diabetic population. Am J Med 2008; 121:1008.
- Matricali GA, Bammens B, Kuypers D, et al. High rate of Charcot foot attacks early after simultaneous pancreas-kidney transplantation. Transplantation 2007; 83:245.
- Slowman-Kovacs SD, Braunstein EM, Brandt KD. Rapidly progressive Charcot arthropathy following minor joint trauma in patients with diabetic neuropathy. Arthritis Rheum 1990; 33:412.
- Forgács SS. Diabetes mellitus and rheumatic disease. Clin Rheum Dis 1986; 12:729.
- Wukich DK, Sung W, Wipf SA, Armstrong DG. The consequences of complacency: managing the effects of unrecognized Charcot feet. Diabet Med 2011; 28:195.
- Armstrong DG, Todd WF, Lavery LA, et al. The natural history of acute Charcot's arthropathy in a diabetic foot specialty clinic. Diabet Med 1997; 14:357.
- Resnick D. Neuroarthropathy. In: Diagnosis of Bone and Joint Disorders, Resnick D, Niwayama G (Eds), WB Saunders, Philadelphia 1981. p.2436.
- Illgner U, van Netten J, Droste C, et al. Diabetic charcot neuroarthropathy of the hand: clinical course, diagnosis, and treatment options. Diabetes Care 2014; 37:e91.
- Illgner U, van Netten J, Droste C, et al. Diabetic charcot neuroarthropathy of the knee: conservative treatment options as alternatives to surgery: case reports of three patients. Diabetes Care 2014; 37:e129.
- Wukich DK, Sung W. Charcot arthropathy of the foot and ankle: modern concepts and management review. J Diabetes Complications 2009; 23:409.
- Rogers LC, Frykberg RG, Armstrong DG, et al. The Charcot foot in diabetes. Diabetes Care 2011; 34:2123.
- Seabold JE, Flickinger FW, Kao SC, et al. Indium-111-leukocyte/technetium-99m-MDP bone and magnetic resonance imaging: difficulty of diagnosing osteomyelitis in patients with neuropathic osteoarthropathy. J Nucl Med 1990; 31:549.
- Ahmadi ME, Morrison WB, Carrino JA, et al. Neuropathic arthropathy of the foot with and without superimposed osteomyelitis: MR imaging characteristics. Radiology 2006; 238:622.
- Höpfner S, Krolak C, Kessler S, et al. Preoperative imaging of Charcot neuroarthropathy in diabetic patients: comparison of ring PET, hybrid PET, and magnetic resonance imaging. Foot Ankle Int 2004; 25:890.
- Kagna O, Srour S, Melamed E, et al. FDG PET/CT imaging in the diagnosis of osteomyelitis in the diabetic foot. Eur J Nucl Med Mol Imaging 2012; 39:1545.
- Gnanasegaran G, Vijayanathan S, Fogelman I. Diagnosis of infection in the diabetic foot using (18)F-FDG PET/CT: a sweet alternative? Eur J Nucl Med Mol Imaging 2012; 39:1525.
- Game FL, Catlow R, Jones GR, et al. Audit of acute Charcot's disease in the UK: the CDUK study. Diabetologia 2012; 55:32.
- Petrova NL, Edmonds ME. Medical management of Charcot arthropathy. Diabetes Obes Metab 2013; 15:193.
- Frykberg RG, Zgonis T, Armstrong DG, et al. Diabetic foot disorders. A clinical practice guideline (2006 revision). J Foot Ankle Surg 2006; 45:S1.
- Pakarinen TK, Laine HJ, Mäenpää H, et al. The effect of zoledronic acid on the clinical resolution of Charcot neuroarthropathy: a pilot randomized controlled trial. Diabetes Care 2011; 34:1514.
- Richard JL, Almasri M, Schuldiner S. Treatment of acute Charcot foot with bisphosphonates: a systematic review of the literature. Diabetologia 2012; 55:1258.
- Selby PL, Young MJ, Boulton AJ. Bisphosphonates: a new treatment for diabetic Charcot neuroarthropathy? Diabet Med 1994; 11:28.
- Jude EB, Selby PL, Burgess J, et al. Bisphosphonates in the treatment of Charcot neuroarthropathy: a double-blind randomised controlled trial. Diabetologia 2001; 44:2032.
- Pitocco D, Ruotolo V, Caputo S, et al. Six-month treatment with alendronate in acute Charcot neuroarthropathy: a randomized controlled trial. Diabetes Care 2005; 28:1214.
- Bem R, Jirkovská A, Fejfarová V, et al. Intranasal calcitonin in the treatment of acute Charcot neuroosteoarthropathy: a randomized controlled trial. Diabetes Care 2006; 29:1392.
- Bono JV, Roger DJ, Jacobs RL. Surgical arthrodesis of the neuropathic foot. A salvage procedure. Clin Orthop Relat Res 1993; :14.
- Thompson RC Jr, Clohisy DR. Deformity following fracture in diabetic neuropathic osteoarthropathy. Operative management of adults who have type-I diabetes. J Bone Joint Surg Am 1993; 75:1765.
- Mueller MJ, Sinacore DR, Hastings MK, et al. Effect of Achilles tendon lengthening on neuropathic plantar ulcers. A randomized clinical trial. J Bone Joint Surg Am 2003; 85-A:1436.
- Raspovic KM, Wukich DK. Self-reported quality of life in patients with diabetes: a comparison of patients with and without Charcot neuroarthropathy. Foot Ankle Int 2014; 35:195.
- CLINICAL FEATURES
- History and physical findings
- Laboratory findings
- Clinical and radiographic staging
- Diagnostic features
- Initial diagnostic evaluation
- Further testing in selected patients
- Differential diagnosis
- - Infections
- - Noninfectious disorders
- Acute and subacute disease
- Joint disorganization and surgical correction
- SUMMARY AND RECOMMENDATIONS