From the Guidelines
Charcot arthropathy is primarily caused by peripheral neuropathy, which leads to loss of protective sensation in joints, with diabetes mellitus being the most common cause worldwide, particularly in patients with long-standing, poorly controlled diabetes who develop peripheral neuropathy. The condition is characterized by an inflammatory process that results in injury to bones, joints, and soft tissues, as described in the guidelines on the diagnosis and treatment of active Charcot neuro-osteoarthropathy in persons with diabetes mellitus 1.
Causes and Risk Factors
The causes of Charcot arthropathy include:
- Diabetes mellitus, particularly in patients with long-standing, poorly controlled diabetes who develop peripheral neuropathy
- Alcoholism
- Syringomyelia
- Tabes dorsalis (tertiary syphilis)
- Leprosy
- Vitamin B12 deficiency
- Spinal cord injuries
- Congenital insensitivity to pain Risk factors for Charcot arthropathy include obesity, previous foot ulcers, and foot surgery 1.
Pathophysiology
The pathophysiology of Charcot arthropathy involves two main theories:
- Neurovascular, where autonomic neuropathy leads to increased blood flow and bone resorption
- Neurotraumatic, where repeated undetected trauma to insensate joints causes progressive damage 1.
Diagnosis and Treatment
Early recognition of Charcot arthropathy is crucial, as the initial inflammatory phase can be mistaken for infection, leading to inappropriate treatment and worsening outcomes 1. The diagnosis of Charcot arthropathy involves clinical findings of an increase in temperature, edema, and/or redness of the foot, compared to the contralateral foot, as well as imaging studies such as plain X-ray or MRI 1. Initiating knee-high immobilization/offloading promptly while further diagnostic studies are performed is recommended to confirm or rule out active Charcot neuro-osteoarthropathy 1.
From the Research
Causes of Charcot Arthropathy
- Charcot arthropathy is a rare progressive disorder of vertebral joint degeneration that occurs in the setting of any condition characterized by decreased afferent innervation with loss of deep pain and proprioceptive sensation in the vertebral column 2
- The disease is often associated with traumatic spinal cord injury, which compromises the biomechanical elements of stability of the spine due to the loss of neuroprotection, leading to joint destruction, deformity, and pain 3
- Other potential causes of Charcot arthropathy include conditions that result in the loss of deep sensation, such as syphilis 3
- Risk factors for the development of Charcot spinal arthropathy include long-segment stabilization, laminectomy, scoliosis, and excessive loading of the spine 4
- The loss of neuroprotection and the resulting joint destruction, deformity, and pain are key factors in the development of Charcot arthropathy 3
Clinical Presentation
- The first clinical symptoms of Charcot spinal arthropathy may include spinal deformity, sitting imbalance, and localized back pain 4
- The diagnosis of Charcot spinal arthropathy is often delayed due to the late onset or slow progression of the disease and the nonspecific nature of the reported clinical signs 4
- Radiological features can assist with diagnosis, but the need for recognition and associated treatment is vital to limit the lifelong disability associated with the disease 3
Management and Complications
- Surgical intervention for Charcot arthropathy is becoming more common, driven by an increased prevalence and better understanding of the cause and risk factors that influence outcomes 5
- Postoperative complications of Charcot spinal arthropathy may include implant loosening, wound healing disturbance, and development of additional Charcot joints 4
- Conservative treatment is an option, but posterior fixation alone does not seem to be sufficient 6