Question-208

A 30 year old female with type 1 DM since 20 years, came with painful foot. She had an x ray done and there was osteopenia and decreased joint space in the tarsal joints. What is the diagnosis?



a. Osteoarthritis
b. Neuropathic joint
c. RA
d. Osteoprosis
e. SLE

Diabetic osteoarthropathy (also known as Charcot or neuropathic arthropathy) is a condition involving destructive, lytic joint changes. It is a severe, destructive form of degenerative arthritis resulting from a loss of sensation (brought on by underlying diabetic neuropathy) in the involved joints. It most commonly affects the pedal bones. Loss of sensation leads to inadvertent (and unnoticed) repeated microtrauma to the joints, which leads to degenerative changes.

The condition is quite rare, affecting only 0.1–0.4% of diabetic patients, and is seen in both type 1 and type 2 diabetes. The average duration of disease in affected patients is 15 years.

Physical examination will invariably demonstrate peripheral neuropathy. There may be skin such as erythema, swelling, hyperpigmentation or purpura, and soft-tissue ulcers over the affected area, as well as joint loosening or instability and joint deformities.

The diagnosis is made based on radiographic findings, with symptoms often milder than would be expected based on the radiographs. There is usually no history of overt trauma.

Depending on the stage and severity of the arthropathy, radiographs can show degenerative changes with subluxation, bone fragments, osteolysis, periosteal reaction, deformity, and/or ankylosis. Computed tomography (CT) scans are insensitive when evaluating for disease activity, whereas magnetic resonance imaging (MRI) and bone scintrigraphy studies are valuable adjuncts to plain films in this regard. The differential diagnosis includes infection, inflammatory processes, degenerative processes, tumor, deep venous thrombosis or thrombophlebitis, and neuropathic arthropathies secondary to other conditions. Diabetic peripheral neuropathy is thought to play the greatest pathogenic role in diabetic osteoarthropathy.

Treatment is generally conservative and unsatisfactory, involving both splinting/bracing to protect the area from weight bearing and good glycemic control. Podiatrists sometimes use a total-contact cast for acute Charcot joints. This must be applied by an experienced cast technician and monitored and changed frequently. Unfortunately, it carries a fairly high risk of causing new injuries and ulcers because of the tight fit and patients’ underlying neuropathy. Broad-spectrum empiric antibiotics are also frequently used when skin ulcers accompany the arthropathy
http://clinical.diabetesjournals.org/content/19/3/132.full
A