eMedicine Specialties > Radiology > Musculoskeletal
Neuropathic Arthropathy (Charcot Joint): Imaging
Updated: May 27, 2008
Radiography
Findings
Neuropathic arthropathy (Charcot joint). Neuropathic arthropathy of the shoulder in a patient with syringomyelia. Note the destruction of the articular surface, dislocation, and debris, which are pathognomonic for a neuropathic joint.
Neuropathic arthropathy (Charcot joint). Neuropathic arthropathy in a patient with syringomyelia. Anteroposterior view of the elbow demonstrates resorption of the bone with opaque subchondral bone.
Neuropathic arthropathy (Charcot joint). Gross disorganization of the hip joints in a patient with tabes dorsalis.
Neuropathic arthropathy (Charcot joint). Fragmentation and collapse of the chondral and osseous structures of both knee joints in a patient with tabes dorsalis.
Neuropathic arthropathy (Charcot joint). Anteroposterior view of the foot in a patient with diabetes and neuropathic arthropathy. Note the fragmentation, collapse, and sclerosis of the intertarsal joints.
- Radiographic findings in the early stage are as follows:
- Persistent or progressive joint effusion
- Narrowing of the joint space
- Soft tissue calcification
- Minimal subluxation
- Preservation of bone density unless infected
- Fragmentation of eburnated subchondral bone
- Radiographic findings in the late stage are as follows:
- Destruction of articular surfaces
- Subchondral sclerosis
- Osteophytosis
- Intra-articular loose bodies (bag of bones)
- Subluxation
- Lisfranc fracture/dislocation of midtarsal bones
- Rapid bone resorption demonstrating pencil-in-a-cup deformity
- Radiographic findings of the complications of septic arthritis are as follows:
- Osteomyelitis
- Bone ankylosis
Radiologic features of neuropathic arthropathy are the same irrespective of the etiology and distribution (see Images above and Images 1-8, 10-13 in Multimedia). Distribution of joint disease varies depending on the etiology. In diabetic neuropathy, common sites of involvement are the metatarsophalangeal, tarsometatarsal, and intertarsal joints. In syringomyelia, neuropathic changes are relatively more common in the shoulder joint, followed by the elbow and wrist. The lower extremities can also be affected in syringomyelia. Changes in the spine are most characteristic in the cervical region.
The joints of the lower extremity are commonly affected in patients with tabes dorsalis. Other sites include the joints of the forefoot and midfoot and the vertebral column. The ankle and intertarsal joints are commonly involved in patients with myelomeningocele and congenital insensitivity to pain (asymbolia). The interphalangeal joints of the hands and the metatarsophalangeal joints of the feet are commonly affected in patients with leprosy. Neuropathic arthropathy associated with chronic alcoholism commonly involves the metatarsophalangeal and interphalangeal joints. The knee and ankle appear to be the predominant sites of involvement in patients with amyloidosis.
Degree of Confidence
Radiographic features found in the severe form of neuropathic arthropathy are pathognomonic, and no further imaging is necessary. Bone eburnation, fracture, subluxation, and joint disorganization can be more profound in this disorder. However, early changes may resemble osteoarthritis, and the bone collapse seen in the late stage may resemble osteonecrosis and posttraumatic osteoarthritis. Radiography is a relatively insensitive modality when used in the diagnosis of osteomyelitis.
False Positives/Negatives
Early features of neuropathic arthropathy, such as joint space narrowing, marginal osteophytosis, and subchondral sclerosis, may resemble osteoarthritis. Neuropathy-like arthropathy can be seen in patients with calcium pyrophosphate dihydrate deposition disease. Bone fragmentation and collapse are manifestations of osteonecrosis, posttraumatic osteoarthritis, intra-articular steroid arthropathy, infection, and alkaptonuria.
Computed Tomography
Findings
Neuropathic arthropathy (Charcot joint). CT scan of the ankle in a patient with neuropathic arthropathy. Note the destruction of the articular surface, disorganization of the joint, and fragmentation.
As with ultrasonography, CT has no significant role in the diagnosis of neuropathic arthropathy. CT may be helpful in evaluating cortical destruction, sequestra, and intraosseous gas (see Image above and Image 9 in Multimedia).
Magnetic Resonance Imaging
Findings
On T1-weighted MRIs, involved joints appear diffusely swollen and demonstrate low signal intensity. The fat plane adjacent to the skin ulceration appears hypointense; when the joints are infected with a gas-producing organism, areas showing a loss of signal intensity are seen. After the intravenous administration of a gadolinium-based contrast agent, the inflammatory mass enhances and demonstrates central nonenhancing necrotic debris.
On short-tau inversion recovery (STIR) sequences, early bone infection may be evidenced by high-signal marrow edema. Later, loss of clarity of the cortical outline and cortical destruction can be identified.
Features that help differentiate spinal neuroarthropathy from disk infection include joint disorganization; facet involvement; debris; a pattern of diffuse signal intensity in the vertebral bodies; spondylolisthesis; and rim enhancement of the disk on gadolinium-enhanced MRIs.12 Features that do not help in differentiation include endplate sclerosis, erosions, osteophytes, a reduction in disk height, and paraspinal soft tissue masses.
Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], gadoteridol [ProHance]) have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). For more information, see the eMedicine topic Nephrogenic Fibrosing Dermopathy. The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans.
NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness. For more information, see the FDA Public Health Advisory or Medscape.
Degree of Confidence
MRI plays a significant role in diagnosing complications. Findings help in assessing the extent of the disease and in determining the presence of osteomyelitis.
False Positives/Negatives
Differentiating bone changes that result from neuropathic arthropathy from those that result from infection is difficult. Bone marrow edema is a nonspecific finding that can be seen in both neuropathic arthropathy and in infection. In general, bone marrow edema found close to a skin ulceration and away from a joint suggests infection.
Ultrasonography
Findings
Ultrasonography has no role in the diagnosis of neuropathic arthropathy. Ultrasonography can be used to identify any local collection when an infection occurs, and it can be used to guide aspiration for obtaining cytologic specimens.
Nuclear Imaging
Findings
The role of radioisotopic studies is to detect osteomyelitis in a neuropathic joint.13 Three-phase phosphate scintigraphy has a high sensitivity (85%) but a low specificity (55%) because of bone remodeling of other causes. Studies using uptake of the gallium-67 citrate have a high false-positive rate. Scanning using indium-111–labeled leukocytes has the highest sensitivity (87%) and specificity (81%) for detecting osteomyelitis in a neuropathic foot. The role of positron emission tomography using fluorodeoxyglucose (FDG) is promising.14
One study has shown a valuable role of FDG PET in the setting of Charcot's neuroarthropathy by reliably differentiating it from osteomyelitis, both in general and when foot ulcer is present.15 In diabetic patients in the setting of concomitant foot ulcer, FDG PET accurately rules out osteomyelitis. Basu and associates estimated the sensitivity and accuracy of FDG PET in the diagnosis of Charcot's foot as 100% and 93.8%, respectively; by contrast, MRI had a sensitivity of 76.9% and an accuracy of 75%.15
Degree of Confidence
Increased uptake on radioisotope scan is seen in both neuropathic joints and in infection. Three-phase bone scan and gallium-67 scintigraphy are sensitive but not specific. Imaging using indium-111-labeled leukocytes has the highest sensitivity and specificity.
False Positives/Negatives
The incidence of false-positive results is increased because of coexisting bone remodeling.
More on Neuropathic Arthropathy (Charcot Joint) |
| Overview: Neuropathic Arthropathy (Charcot Joint) |
 Imaging: Neuropathic Arthropathy (Charcot Joint) |
| Follow-up: Neuropathic Arthropathy (Charcot Joint) |
| Multimedia: Neuropathic Arthropathy (Charcot Joint) |
| References |
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References
Bar-On E, Floman Y, Sagiv S, et al. Orthopaedic manifestations of familial dysautonomia. A review of one hundred and thirty-six patients. J Bone Joint Surg Am. Nov 2000;82-A(11):1563-70. [Medline].
Bloomgarden ZT. American Diabetes Association 60th Scientific Sessions, 2000: the diabetic foot. Diabetes Care. May 2001;24(5):946-51. [Medline].
Deirmengian CA, Lee SG, Jupiter JB. Neuropathic arthropathy of the elbow. A report of five cases. J Bone Joint Surg Am. Jun 2001;83-A(6):839-44. [Medline].
Jones EA, Manaster BJ, May DA, Disler DG. Neuropathic osteoarthropathy: diagnostic dilemmas and differential diagnosis. Radiographics. Oct 2000;20 Spec No:S279-93. [Medline].
Kapila A, Lines M. Neuropathic spinal arthropathy: CT and MR findings. J Comput Assist Tomogr. Jul-Aug 1987;11(4):736-9. [Medline].
Sommer TC, Lee TH. Charcot foot: the diagnostic dilemma. Am Fam Physician. Nov 1 2001;64(9):1591-8. [Medline].
Sanders LJ. What lessons can history teach us about the Charcot foot?. Clin Podiatr Med Surg. Jan 2008;25(1):1-15. [Medline].
Koop I, Loreck D, Krause A. Diabetic neuropathic arthropathy. Arthritis Rheum. Apr 1999;42(4):806. [Medline].
Rostom S, Bahiri R, Mahfoud-Filali S, Hajjaj-Hassouni N. Neurogenic osteoarthropathy in leprosy. Clin Rheumatol. Dec 2007;26(12):2153-5. [Medline].
Soysal N, Ayhan M, Guney E, Akyol A. Differential diagnosis of Charcot arthropathy and osteomyelitis. Neuro Endocrinol Lett. Oct 2007;28(5):556-9. [Medline].
Devendra D, Farmer K, Bruce G, et al. Diagnosing osteomyelitis in patients with diabetic neuropathic osteoarthropathy. Diabetes Care. Dec 2001;24(12):2154-5. [Medline].
Wagner SC, Schweitzer ME, Morrison WB, et al. Can imaging findings help differentiate spinal neuropathic arthropathy from disk space infection? Initial experience. Radiology. Mar 2000;214(3):693-9. [Medline].
Palestro CJ, Mehta HH, Patel M, et al. Marrow versus infection in the Charcot joint: indium-111 leukocyte and technetium-99m sulfur colloid scintigraphy. J Nucl Med. Feb 1998;39(2):346-50. [Medline].
Alnafisi N, Yun M, Alavi A. F-18 FDG positron emission tomography to differentiate diabetic osteoarthropathy from septic arthritis. Clin Nucl Med. Jul 2001;26(7):638-9. [Medline].
Basu S, Chryssikos T, Houseni M, Scot Malay D, Shah J, Zhuang H, et al. Potential role of FDG PET in the setting of diabetic neuro-osteoarthropathy: can it differentiate uncomplicated Charcot's neuroarthropathy from osteomyelitis and soft-tissue infection?. Nucl Med Commun. Jun 2007;28(6):465-72. [Medline].
Judge MS. Infection and neuroarthropathy: the utility of C-reactive protein as a screening tool in the Charcot foot. J Am Podiatr Med Assoc. Jan-Feb 2008;98(1):1-6. [Medline].
Naqvi A, Cuchacovich R, Saketkoo L, Espinoza LR. Acute Charcot arthropathy successfully treated with pamidronate: long-term follow-up. Am J Med Sci. Feb 2008;335(2):145-8. [Medline].
Noonan KJ, Didelot WP, Lindseth RE. Care of the pediatric foot in myelodysplasia. Foot Ankle Clin. Jun 2000;5(2):281-304, vi. [Medline].
Pitocco D, Collina MC, Musella T, Ruotolo V, Caputo S, Manto A, et al. Interaction between IGF-1, inflammation, and neuropathy in the pathogenesis of acute charcot neuroarthropathy: lessons from alendronate therapy and future perspectives of medical therapy. Horm Metab Res. Mar 2008;40(3):163-4. [Medline].
Sliwa JA, Rippe D, Do V. Charcot spine in a person with congenital insensitivity to pain with anhydrosis: a case report of re-diagnosis. Arch Phys Med Rehabil. Mar 2008;89(3):568-71. [Medline].
Sutterfield R. Light therapy and advanced wound care for a neuropathic plantar ulcer on a Charcot foot. J Wound Ostomy Continence Nurs. Jan-Feb 2008;35(1):113-5; discussion 116-7. [Medline].
Further Reading
Keywords
neurotrophic joint, neuropathic joint disease, neuroarthropathy, Charcot joint disease, arthropathy, neuropathic osteoarthropathy, destruction of articular surfaces, dense subchondral bones, joint debris, joint deformity, dislocation, hypertrophic neuropathic osteoarthropathy, atrophic neuropathic osteoarthropathy, disorganized joints
