Roentgen Observations in Diabetic Osteopathy

Diabetic osteopathy (diabetic neuroarthropathy, diabetic neuro-osteo-arthropathy, diabetic Charcot joint, diabetic foot) and in particular its pathogenesis are inadequately understood. In this presentation the term “osteopathy” is preferred to “arthropathy” because the disease is primarily one of the bones and any joint involvement is secondary (20). The purpose of this communication is to promote a better insight into the nature and dynamics of the disease, with emphasis on follow-up studies. Material and Incidence Thirty-eight cases of diabetic osteopathy were reviewed, 36 of these patients being observed during the last ten years. This number of cases is not a correct representation of the incidence of the disease in the District of Columbia General Hospital because only those cases with well documented bony manifestations are reported here. Twenty-two (58 per cent) of the 38 patients were females, and 16 (42 per cent) were male. In 15 cases no exact statement as to the duration of the diabetes was available, but in 17 patients (74 per cent) the disease was of more than ten years duration. Twenty-five patients (66 per cent) were over the age of fifty years, and the age incidence in the entire group ranged between thirty and seventy-six years. The diabetes was inadequately controlled in many of the patients, but in some cases it was mild or even subclinical. The distribution of the bone changes is shown in Table I. It is interesting to note that the right side was involved nearly twice as often as the left. In half the patients the bone disease was bilateral. Clinical Considerations Diabetic osteopathy is generally associated with soft-tissue changes of variable degree and extent. There may be redness and soft-tissue swelling of the part involved or, more commonly, perforating ulcer or gangrene. The diabetic ulcer {malum perforans pedis) is a deep undermined soft-tissue defect with a punched-out appearance; it is usually painless. It is seen most often on the plantar surface. Some degree of neurological deficit, a manifestation of diabetic neuropathy, nearly always accompanies the bone and soft-tissue disease. These deficits, mainly sensory, include absence or diminution of (a) pain and proprioceptive sensations, and (b) the deep tendon reflexes. The absence or diminution of the deep tendon reflexes most commonly affects the ankles, less often the knees. Arteriosclerosis is common, with an autopsy incidence 56 times that in nondiabetics (2). Calcification in the wall of the small metatarsal and digital arteries is a relatively frequent roentgen observation; in the present material it was found in 18 of the patients (40.2 per cent). In all the cases of this communication ulcer or gangrene was present. Differentiation between diabetic soft-tissue necrosis and an arteriosclerotic necrosis may be difficult.