The Acute Neuropathic Arthropathy—A Rapid, Severely Disorganizing Form of Arthritis

The pathogenesis of neuropathic arthropathy is well understood, but little has been written about the acute neuropathic joint and its clinical-roentgenographic appearance. In 1868 Charcot (1) described “the arthropathy of ataxic patients” developing rapidly in the absence of trauma and showing in nine weeks severe disorganization of the joint. The rapidity with which destruction can take place in a neuropathic joint has been given little attention. It is the purpose of this paper to emphasize the rapidly destructive phase of the neuropathic joint and the early recognition of the roentgenographic changes. Clinical Material The authors' observations are based upon a series of 8 patients with acute neuropathic joints. Although the pertinent data in this clinical group are listed in Table I, there are features which deserve discussion in further detail. Age and Sex Of the 8 patients studied, the youngest was twenty-six years old and the eldest sixty-nine—both females. Only 2 in the group were younger than fifty years of age. There was no predilection for sex; the 8 patients were equally divided between male and female. Affected Joints There was involvement of the joints of the upper and lower extremities. Of the 5 cases in which the lower extremity was affected, the hip was involved in one, the knee in 2, and the feet in 2 others. The shoulder was the only joint affected in 3 patients with upper extremity lesions. Rapidity of Evolution The authors considered the lesion an acute neuropathic arthropathy if fragmentation of the articular ends of the bone and subluxation occurred in less than eight weeks. Seven of the 8 patients had destruction of their affected joints within this period. In Case IV, however, three months elapsed before the roentgenographic changes of advanced neuroarthropathy were noted. This patient, a diabetic, was seen because of “ankle sprain,” and the initial roentgenogram revealed an unsuspected linear fracture through the tarsal navicular bone. The patient returned for a re-examination after three months because he had had relatively little discomfort in the interim in spite of massive swelling of the ankle and foot. The repeat roentgenogram demonstrated advanced disorganization of the midtarsus. It was evident that although fragmentation in this case occurred slightly after the two month limit selected for the group, the advanced changes already present on the roentgenogram at the second visit implied rapid progression of the neuropathic disorder. Of the other 7 patients, the shortest period in which advanced joint destruction took place was nine days. In most instances a normal roentgenogram, or one showing minimal roentgenographic findings which were often mistaken for mild osteoarthritis, was available at the onset of symptoms. Underlying Disorder The neuropathies were a complication of a variety of neurologic conditions.