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Semin Musculoskelet Radiol 2010; 14(3): 365-376
DOI: 10.1055/s-0030-1254525
© Thieme Medical Publishers

Neuro-osteoarthropathy of the Foot—Radiologist: Friend or Foe?

Ivo G. Schoots1 , Frederik J. Slim2 , Tessa E. Busch-Westbroek2 , Mario Maas1
  • 1Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
  • 2Department of Rehabilitation Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Publication History

Publication Date:
10 June 2010 (online)

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ABSTRACT

Charcot neuro-osteoarthropathy is a significant problem with a rapid devastating nature. If not recognized it may lead to progressive foot deformity, ulceration or osteomyelitis, or eventually to amputation. The diagnosis is challenging, and imaging plays a pivotal role. Rapid and accurate diagnosis and early intervention is important to prevent progressive and destructive Charcot deformity of the foot.

The imaging workup of the warm swollen Charcot foot is presented. The advantages and disadvantages of different imaging modalities are discussed. This review provides the consulting radiologists with tools to cautiously differentiate Charcot's neuro-osteoarthropathy from osteomyelitis. It is crucial to look beyond radiological features and integrate the location of pathology and presence of ulcer in the reading process. Because imaging plays a pivotal role in arriving at the definitive diagnosis and adequate treatment, the radiologist “makes the difference”—can be a friend or a foe.

KEYWORDS

Charcot - neuro-osteoarthropathy - osteomyelitis - foot - imaging - diabetes

REFERENCES

  • 1 Lavery L A, Armstrong D G, Wunderlich R P, Tredwell J, Boulton A J. Diabetic foot syndrome: evaluating the prevalence and incidence of foot pathology in Mexican Americans and non-Hispanic whites from a diabetes disease management cohort.  Diabetes Care. 2003;  26(5) 1435-1438
    CrossrefPubMedGoogle Scholar
  • 2 Smith D G, Barnes B C, Sands A K, Boyko E J, Ahroni J H. Prevalence of radiographic foot abnormalities in patients with diabetes.  Foot Ankle Int. 1997;  18(6) 342-346
    PubMedGoogle Scholar
  • 3 Nabarro J D. Diabetes in the United Kingdom: a personal series.  Diabet Med. 1991;  8(1) 59-68
    CrossrefPubMedGoogle Scholar
  • 4 Holewski J J, Moss K M, Stess R M, Graf P M, Grunfeld C. Prevalence of foot pathology and lower extremity complications in a diabetic outpatient clinic.  J Rehabil Res Dev. 1989;  26(3) 35-44
    PubMedGoogle Scholar
  • 5 Sinha S, Munichoodappa C S, Kozak G P. Neuro-arthropathy (Charcot joints) in diabetes mellitus (clinical study of 101 cases).  Medicine (Baltimore). 1972;  51(3) 191-210
    CrossrefPubMedGoogle Scholar
  • 6 Armstrong D G, Todd W F, Lavery L A, Harkless L B, Bushman T R. The natural history of acute Charcot's arthropathy in a diabetic foot specialty clinic.  Diabet Med. 1997;  14(5) 357-363
    CrossrefPubMedGoogle Scholar
  • 7 Parkhouse N, Le Quesne P M. Impaired neurogenic vascular response in patients with diabetes and neuropathic foot lesions.  N Engl J Med. 1988;  318(20) 1306-1309
    CrossrefPubMedGoogle Scholar
  • 8 Sanders L Y, Frykberg R G. Charcot joint. In: Levin ME, O'Neal LW, Bowker JH The Diabetic Foot 2nd ed. St. Louis, MO; Mosby 1993
    PubMedGoogle Scholar
  • 9 Onvlee G J. The Charcot Foot. A Critical Review and an Observational Study of a Group of 60 Patients [thesis]. Leiden, The Netherlands; University of Leiden 1998
    PubMedGoogle Scholar
  • 10 Sanders L JFR. Charcot neuroarthropathy of the foot. In: Levin ME, O'Neal LW, Bowker JH, Pfiefer MA The Diabetic Foot. 6th ed. St. Louis, MO; Mosby 2001: 439-465
    PubMedGoogle Scholar
  • 11 Gazis A, Pound N, Macfarlane R, Treece K, Game F, Jeffcoate W. Mortality in patients with diabetic neuropathic osteoarthropathy (Charcot foot).  Diabet Med. 2004;  21(11) 1243-1246
    CrossrefPubMedGoogle Scholar
  • 12 Sohn M W, Lee T A, Stuck R M, Frykberg R G, Budiman-Mak E. Mortality risk of Charcot arthropathy compared with that of diabetic foot ulcer and diabetes alone.  Diabetes Care. 2009;  32(5) 816-821
    CrossrefPubMedGoogle Scholar
  • 13 Dahmen R, De Jong B A, Lankhorst G J, Michels R PJ. Charcot foot in diabetes mellitus: a study on the relation between impairment and disability.  J Rehabil Sci. 1995;  8 46-50
    PubMedGoogle Scholar
  • 14 Schon L C, Easley M E, Weinfeld S B. Charcot neuroarthropathy of the foot and ankle.  Clin Orthop Relat Res. 1998;  (349) 116-131
    PubMedGoogle Scholar
  • 15 Caputo G M, Ulbrecht J, Cavanagh P R, Juliano P. The Charcot foot in diabetes: six key points.  Am Fam Physician. 1998;  57(11) 2705-2710
    PubMedGoogle Scholar
  • 16 Petrova N L, Moniz C, Elias D A, Buxton-Thomas M, Bates M, Edmonds M E. Is there a systemic inflammatory response in the acute Charcot foot?.  Diabetes Care. 2007;  30(4) 997-998
    CrossrefPubMedGoogle Scholar
  • 17 Clouse M E, Gramm H F, Legg M, Flood T. Diabetic osteoarthropathy. Clinical and roentgenographic observations in 90 cases.  Am J Roentgenol Radium Ther Nucl Med. 1974;  121(1) 22-34
    CrossrefPubMedGoogle Scholar
  • 18 Apelqvist J, Bakker K, van Houtum W H, Schaper N C. International Working Group on the Diabetic Foot (IWGDF) Editorial Board . Practical guidelines on the management and prevention of the diabetic foot: based upon the International Consensus on the Diabetic Foot (2007) prepared by the International Working Group on the Diabetic Foot.  Diabetes Metab Res Rev. 2008;  24(suppl 1) S181-S187
    CrossrefPubMedGoogle Scholar
  • 19 Lipsky B A, Pecoraro R E, Wheat L J. The diabetic foot. Soft tissue and bone infection.  Infect Dis Clin North Am. 1990;  4(3) 409-432
    PubMedGoogle Scholar
  • 20 Beltran J, Campanini D S, Knight C, McCalla M. The diabetic foot: magnetic resonance imaging evaluation.  Skeletal Radiol. 1990;  19(1) 37-41
    PubMedGoogle Scholar
  • 21 Ledermann H P, Morrison W B, Schweitzer M E. Pedal abscesses in patients suspected of having pedal osteomyelitis: analysis with MR imaging.  Radiology. 2002;  224(3) 649-655
    CrossrefPubMedGoogle Scholar
  • 22 Ahmadi M E, Morrison W B, Carrino J A, Schweitzer M E, Raikin S M, Ledermann H P. Neuropathic arthropathy of the foot with and without superimposed osteomyelitis: MR imaging characteristics.  Radiology. 2006;  238(2) 622-631
    CrossrefPubMedGoogle Scholar
  • 23 Grayson M L, Gibbons G W, Balogh K, Levin E, Karchmer A W. Probing to bone in infected pedal ulcers. A clinical sign of underlying osteomyelitis in diabetic patients.  JAMA. 1995;  273(9) 721-723
    CrossrefPubMedGoogle Scholar
  • 24 Morrison W B, Schweitzer M E, Batte W G, Radack D P, Russel K M. Osteomyelitis of the foot: relative importance of primary and secondary MR imaging signs.  Radiology. 1998;  207(3) 625-632
    CrossrefPubMedGoogle Scholar
  • 25 Morrison W B, Schweitzer M E, Bock G W et al.. Diagnosis of osteomyelitis: utility of fat-suppressed contrast-enhanced MR imaging.  Radiology. 1993;  189(1) 251-257
    CrossrefPubMedGoogle Scholar
  • 26 Cavanagh P R, Young M J, Adams J E, Vickers K L, Boulton A J. Radiographic abnormalities in the feet of patients with diabetic neuropathy.  Diabetes Care. 1994;  17(3) 201-209
    CrossrefPubMedGoogle Scholar
  • 27 Eichenholtz S. Charcot Joints. Springfield, IL; Charles Thomas 1966
    PubMedGoogle Scholar
  • 28 Shibata T, Tada K, Hashizume C. The results of arthrodesis of the ankle for leprotic neuroarthropathy.  J Bone Joint Surg Am. 1990;  72(5) 749-756
    PubMedGoogle Scholar
  • 29 Yu G V, Hudson J R. Evaluation and treatment of stage 0 Charcot's neuroarthropathy of the foot and ankle.  J Am Podiatr Med Assoc. 2002;  92(4) 210-220
    PubMedGoogle Scholar
  • 30 Sella E J, Barrette C. Staging of Charcot neuroarthropathy along the medial column of the foot in the diabetic patient.  J Foot Ankle Surg. 1999;  38(1) 34-40
    CrossrefPubMedGoogle Scholar
  • 31 Sammak B, Abd El Bagi M, Al Shahed M et al.. Osteomyelitis: a review of currently used imaging techniques.  Eur Radiol. 1999;  9(5) 894-900
    CrossrefPubMedGoogle Scholar
  • 32 Sella E J. Current concepts review: diagnostic imaging of the diabetic foot.  Foot Ankle Int. 2009;  30(6) 568-576
    CrossrefPubMedGoogle Scholar
  • 33 Dinh M T, Abad C L, Safdar N. Diagnostic accuracy of the physical examination and imaging tests for osteomyelitis underlying diabetic foot ulcers: meta-analysis.  Clin Infect Dis. 2008;  47(4) 519-527
    CrossrefPubMedGoogle Scholar
  • 34 Chatha D S, Cunningham P M, Schweitzer M E. MR imaging of the diabetic foot: diagnostic challenges.  Radiol Clin North Am. 2005;  43(4) 747-759
    CrossrefPubMedGoogle Scholar
  • 35 Ledermann H P, Morrison W B, Schweitzer M E, Raikin S M. Tendon involvement in pedal infection: MR analysis of frequency, distribution, and spread of infection.  AJR Am J Roentgenol. 2002;  179(4) 939-947
    PubMedGoogle Scholar
  • 36 Marcus C D, Ladam-Marcus V J, Leone J, Malgrange D, Bonnet-Gausserand F M, Menanteau B P. MR imaging of osteomyelitis and neuropathic osteoarthropathy in the feet of diabetics.  Radiographics. 1996;  16(6) 1337-1348
    CrossrefPubMedGoogle Scholar
  • 37 Miller T T, Randolph Jr D A, Staron R B, Feldman F, Cushin S. Fat-suppressed MRI of musculoskeletal infection: fast T2-weighted techniques versus gadolinium-enhanced T1-weighted images.  Skeletal Radiol. 1997;  26(11) 654-658
    CrossrefPubMedGoogle Scholar
  • 38 Petrova N L, Edmonds M E. Charcot neuro-osteoarthropathy—current standards.  Diabetes Metab Res Rev. 2008;  24(suppl 1) S58-S61
    CrossrefPubMedGoogle Scholar
  • 39 Yu J S. Diabetic foot and neuroarthropathy: magnetic resonance imaging evaluation.  Top Magn Reson Imaging. 1998;  9(5) 295-310
    PubMedGoogle Scholar
  • 40 Croll S D, Nicholas G G, Osborne M A, Wasser T E, Jones S. Role of magnetic resonance imaging in the diagnosis of osteomyelitis in diabetic foot infections.  J Vasc Surg. 1996;  24(2) 266-270
    CrossrefPubMedGoogle Scholar
  • 41 Wang A, Weinstein D, Greenfield L et al.. MRI and diabetic foot infections.  Magn Reson Imaging. 1990;  8(6) 805-809
    CrossrefPubMedGoogle Scholar
  • 42 Weinstein D, Wang A, Chambers R, Stewart C A, Motz H A. Evaluation of magnetic resonance imaging in the diagnosis of osteomyelitis in diabetic foot infections.  Foot Ankle. 1993;  14(1) 18-22
    PubMedGoogle Scholar
  • 43 Ledermann H P, Morrison W B, Schweitzer M E. MR image analysis of pedal osteomyelitis: distribution, patterns of spread, and frequency of associated ulceration and septic arthritis.  Radiology. 2002;  223(3) 747-755
    CrossrefPubMedGoogle Scholar
  • 44 Levine S E, Neagle C E, Esterhai J L, Wright D G, Dalinka M K. Magnetic resonance imaging for the diagnosis of osteomyelitis in the diabetic patient with a foot ulcer.  Foot Ankle Int. 1994;  15(3) 151-156
    PubMedGoogle Scholar
  • 45 Morrison W B, Schweitzer M E, Wapner K L, Hecht P J, Gannon F H, Behm W R. Osteomyelitis in feet of diabetics: clinical accuracy, surgical utility, and cost-effectiveness of MR imaging.  Radiology. 1995;  196(2) 557-564
    CrossrefPubMedGoogle Scholar
  • 46 Nigro N D, Bartynski W S, Grossman S J, Kruljac S. Clinical impact of magnetic resonance imaging in foot osteomyelitis.  J Am Podiatr Med Assoc. 1992;  82(12) 603-615
    PubMedGoogle Scholar
  • 47 Moore T E, Yuh W T, Kathol M H, el-Khoury G Y, Corson J D. Abnormalities of the foot in patients with diabetes mellitus: findings on MR imaging.  AJR Am J Roentgenol. 1991;  157(4) 813-816
    CrossrefPubMedGoogle Scholar
  • 48 Tomas M B, Patel M, Marwin S E, Palestro C J. The diabetic foot.  Br J Radiol. 2000;  73(868) 443-450
    PubMedGoogle Scholar
  • 49 Morrison W B, Ledermann H P, Schweitzer M E. MR imaging of the diabetic foot.  Magn Reson Imaging Clin N Am. 2001;  9(3) 603-613 xi
    PubMedGoogle Scholar
  • 50 Berendt A R, Peters E J, Bakker K et al.. Specific guidelines for treatment of diabetic foot osteomyelitis.  Diabetes Metab Res Rev. 2008;  24(suppl 1) S190-S191
    CrossrefPubMedGoogle Scholar
  • 51 Schweitzer M E, Morrison W B. MR imaging of the diabetic foot.  Radiol Clin North Am. 2004;  42(1) 61-71 vi
    CrossrefPubMedGoogle Scholar
  • 52 Morrison W B, Ledermann H P, Schweitzer M E. MR imaging of inflammatory conditions of the ankle and foot.  Magn Reson Imaging Clin N Am. 2001;  9(3) 615-637 xi-xii xi-xii
    PubMedGoogle Scholar
  • 53 Boutin R D, Brossmann J, Sartoris D J, Reilly D, Resnick D. Update on imaging of orthopedic infections.  Orthop Clin North Am. 1998;  29(1) 41-66
    CrossrefPubMedGoogle Scholar
  • 54 Chantelau E. The perils of procrastination: effects of early vs. delayed detection and treatment of incipient Charcot fracture.  Diabet Med. 2005;  22(12) 1707-1712
    CrossrefPubMedGoogle Scholar
  • 55 Amital H, Applbaum Y H, Bar-On H, Rubinow A. Inside a Charcot joint.  Isr Med Assoc J. 2003;  5(6) 458-459
    PubMedGoogle Scholar
  • 56 Gold R H, Tong D J, Crim J R, Seeger L L. Imaging the diabetic foot.  Skeletal Radiol. 1995;  24(8) 563-571
    PubMedGoogle Scholar
  • 57 Berquist T H, Brown M L, Fitzgerald Jr R H, May G R. Magnetic resonance imaging: application in musculoskeletal infection.  Magn Reson Imaging. 1985;  3(3) 219-230
    CrossrefPubMedGoogle Scholar
  • 58 Keenan A M, Tindel N L, Alavi A. Diagnosis of pedal osteomyelitis in diabetic patients using current scintigraphic techniques.  Arch Intern Med. 1989;  149(10) 2262-2266
    CrossrefPubMedGoogle Scholar
  • 59 Palestro C J, Mehta H H, Patel M et al.. Marrow versus infection in the Charcot joint: indium-111 leukocyte and technetium-99m sulfur colloid scintigraphy.  J Nucl Med. 1998;  39(2) 346-350
    PubMedGoogle Scholar
  • 60 Alazraki N, Dries D, Datz F, Lawrence P, Greenberg E, Taylor Jr A. Value of a 24-hour image (four-phase bone scan) in assessing osteomyelitis in patients with peripheral vascular disease.  J Nucl Med. 1985;  26(7) 711-717
    PubMedGoogle Scholar
  • 61 Capriotti G, Chianelli M, Signore A. Nuclear medicine imaging of diabetic foot infection: results of meta-analysis.  Nucl Med Commun. 2006;  27(10) 757-764
    CrossrefPubMedGoogle Scholar
  • 62 Keidar Z, Militianu D, Melamed E, Bar-Shalom R, Israel O. The diabetic foot: initial experience with 18F-FDG PET/CT.  J Nucl Med. 2005;  46(3) 444-449
    PubMedGoogle Scholar
  • 63 Basu S, Chryssikos T, Houseni M 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. 2007;  28(6) 465-472
    CrossrefPubMedGoogle Scholar
  • 64 Schwegler B, Stumpe K D, Weishaupt D et al.. Unsuspected osteomyelitis is frequent in persistent diabetic foot ulcer and better diagnosed by MRI than by 18F-FDG PET or 99mTc-MOAB.  J Intern Med. 2008;  263(1) 99-106
    PubMedGoogle Scholar

Ivo G SchootsM.D. 

Department of Radiology, C1-211, Academic Medical Center, University of Amsterdam, Meibergdreef 9

1105 AZ, Amsterdam, The Netherlands

Email: i.g.schoots@amc.uva.nl

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