Neuropathic Arthropathy

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Neuropathic Arthropathy is a chronic, progressive degenerative disorder affecting one or more peripheral or vertebral articulations, which develops as the result of a disturbance in the normal sensory innervation of joints. Diabetes, syphilis, and syringomelia are the most commonly associated clinical entities. When it is suspected, careful clinical evaluation should be performed to identify an underlying neurologic disorder. Patient education, joint protection, and early recognition of fractures are the most important general management principles. Surgery can be considered in cases of advanced joint destruction when there is significant disability.

There are three stages of neuropathic arthropathy:

FIRST STAGE is a fragmentation or destruction stage. During this stage, as the process begins, the joint and surrounding bone is destroyed. The bone fragments, the joint becomes unstable and in some cases the bone is completely reabsorbed. This stage is clinically identified by significant swelling redness, and warmth or heat to the area. It is easy to see why this is often confused with an infection, especially as there is often no history of injury or trauma. As the bones and joint are affected, fractures and instability develop and the joints can dislocate or shift in relationship to each other. This can lead to severe deformity of the foot and ankle. Most often the midfoot joints are affected and the result is a very flat foot which is wide where the normal foot narrows in the arch. Bony prominences often develop on the plantar (bottom) surface of the foot. Diagnosis and early treatment at this stage is important to try to minimize the bone destruction and deformity. This process may last as long as six to 12 months.

SECOND STAGE of neuropathic arthropathyis is termed coalescence. During this stage the acute destructive process slows down and the body begins to try and heal itself. The swelling and heat begin to disappear. Once the acute process is resolved and the healing on-going, the third stage begins.

THIRD STAGE is a consolidation or reconstruction phase during which the bones and joints heal. Unfortunately, the foot is often deformed, and if there has been enough destruction, there may be residual instability. Fitting shoes may be very difficult,and prescription footwear and diabetic shoe inserts are important to help prevent ulcer formation over deformed areas.

Most patients who develop neuropathic arthropathy have peripheral neuropathy after being diabetic about 10 years or longer. So a patient with juvenile-onset diabetes (as a child) may develop this in his 20s or 30s. However, most patients with Charcot arthropathy are in their 40s or older, as more patients have adult-onset diabetes.

Once neuropathic arthropathy has been diagnosed there are several important treatment goals. The first is to get the heat and swelling under control. The second is to support or stabilize the foot to minimize deformity. A total contact cast is applied by trained personnel. This cast has more padding than a standard cast and is often applied with the toes completely covered to prevent foreign objects from getting in the cast. The cast will need to be changed frequently initially as it may get loose quickly as the swelling is controlled. Once the initial swelling is controlled and the patient is tolerating the casts without skin problems, the cast change interval may be lengthened to two to four weeks. Another alternative is fabrication of a custom walking boot for diabetics. The foot must be supported until all heat and swelling has resolved. This may occur in several months but more commonly requires six to 12 months. Minimizing weight-bearing on the affected foot/ankle is also important. Realistically this is extremely difficult for the patient with diabetic neuropathy and should be encouraged. Assistive aides such as a walker or cast are recommended. During this period the patient will be seen frequently in the office. Continued education about diabetic foot care and neuropathic arthropathy is necessary. Also, support of the various stages of anger and denial concerning this rather profound change is necessary. After the first stage is completed, molds for appropriate diabetic footwear, orthotics and braces are made. During treatment it is important to check the noninvolved foot and protect it, as that foot is doing much more work.

For patients who develop deformities that are unshoeable or bracable, or who develop unbracable instability, surgery may be considered. The timing for this surgery is important. Surgery done during the inflammatory stage may have a high complication rate. Sometimes, however, surgery must be done during this stage due to joint instability. Another option for severe deformity/instability is amputation and prosthetic fitting. Patients often have multiple medical problems which must be taken into account in consideration for any surgery. It is important to be treated by a medical doctor who is trained in the breadth of medical problems that affect people with diabetes.

Long-term management of patients with Charcot Arthropathy is important. Once the patient is stable, periodic checkups with a qualified foot and ankle specialist is important to identify early complications, address footwear, orthotic and brace issues, and continue patient education regarding the care of diabetic feet and the special needs of the patient with Charcot arthropathy. Patients should be counseled to seek medical care if they develop any redness, swelling, or heat in their feet, as this could be the start of another Charcot process.


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