Charcot neuroarthropathy : pathogenesis, diagnosis and medical management

Abstract

Charcot neuroarthropathy (CN) is a progressive degenerative arthropathy which rarely complicates diabetes mellitus. Most commonly, though not exclusively affecting the foot, it seems to be determined by the interaction of neuropathy, osteopaenia and proinflammatory cytokines on a calcified peripheral vasculature that maintains its ability to vasodilate despite widespread arteriosclerosis. Although often unrecalled, this arthropathy is probably triggered by trauma. Diagnosis is essentially clinical, given the paucity and non-specificity of radiological and biochemical findings at the acute stage. CN should be considered in the differential diagnosis of any diabetic patient presenting with a warm swollen lower extremity. Bone turnover markers, magnetic resonance imaging and radioisotope scanning may be useful diagnostic aids. Offloading is essential and improves limb survival. There is considerable interest, though limited data, on the benefits of bisphosphonates and calcitonin. The possible roles of ultrasound and radiotherapy need to be assessed in larger trials. Failure to institute corrective measures at an early stage results in a foot that is prone to deformity, ulceration, amputation and loss of function. It is hoped that a better understanding of the aetiopathogenesis at a cytokine level will allow the targeting of new effective agents.