Description

• A progressive destructive arthritis secondary to peripheral neuropathy and the associated loss of pain sensation. The affected joints are subjected to repeated stress that is unrecognized by the patient, causing damage to underlying bone and cartilage.
• Synonym(s): neuropathic joint disease/arthropathy; Charcot joint disease
• Two pathologic theories: neurovascular and neurotraumatic
• 60% of cases are in tarsal and tarsometatarsal joints, 30% in metatarsophalangeal and talotibial joints; may also be seen in knee, hip, spine
• Upper extremity joints are rarely involved (seen in syringomyelia).
• Affected systems: musculoskeletal, endocrine, and neurologic
• DM is the most common cause in the United States.
• There are four stages of Charcot arthropathy.
  • Modified Eichenholtz classification:
    • Stage 0—prodromal: joint edema, negative radiographs
    • Stage I—development: joint fragmentation and destruction
    • Stage II—coalescence
    • Stage III—reconstruction: consolidation/resolution (1)[C]
• Refer neuropathic arthropathy patients promptly to an orthopedic surgeon or podiatrist.

Epidemiology

• Usually occurs 8 to 12 years after diagnosis of DM
• Seen mostly in the 5th and 6th decades but can be seen in patients as young as 20 years
• Men > females
• 30% bilateral incidence
• 77% prevalence in patients with DM
• Prevalence without DM 11.7% (2)

Incidence

• 3 to 11.7/1,000 patients per year
• 1/600 to 700 in the United States have diabetes.

Prevalence

• 0.1% in all patients
• 0.8–8% in with the general DM population
• Up to 13% in high-risk diabetic patients (3)

Etiology and Pathophysiology

• Exact cause is unknown.
  • Two pathologic theories:
    • Neurotraumatic: Repeated minor trauma of pedal bones in patient unable to perceive pain leads to multiple fractures and collapse of normal architecture (2).
    • Neurovascular: Loss of sympathetic function leads to destruction of bone secondary to hypervascular state. Increased blood flow causes leaking of bone minerals, osteopenia, and fracture (2).
• Causes of peripheral neuropathy:
  • DM
  • Multiple sclerosis
  • Raynaud disease
  • Connective tissue disease (i.e., rheumatoid arthritis [RA], scleroderma)
  • Syphilis/tabes dorsalis
  • Syringomyelia, upper extremity disease
  • Meningomyelocele
  • Frequent intra-articular steroid injections
  • Alcoholism, pernicious anemia
  • Charcot-Marie-Tooth disease
  • Leprosy
  • Dialysis, amyloidosis
  • Trauma, spinal or peripheral nerve injury

Risk Factors

• DM >10-year, especially if poorly controlled
• Poor foot hygiene
• Syphilis, leprosy
• Concomitant arthritis (osteoarthritis, RA)