Total knee arthroplasty for neuropathic arthropathy in a patient with leprosy.

Patients with leprosy are known to tend to develop neuropathic arthropathy, known as Charcot joint. There are no case reports of total knee arthroplasty (TKA) in patients with leprosy with polyarticular neuropathic arthropathy, and the results are unknown. In this study, we report a case of TKA in a patient with leprosy with polyarticular neuropathic arthropathy and discuss its outcomes and indications. Right TKA using the NexGen Legacy Constrained Condylar Knee implant was performed in a 62-year-old man with neuropathic arthropathy in multiple joints with clinical symptoms, particularly in the right knee. Seven years post-operation, the American Knee Society Score-knee and -function, which represent knee function and activities of daily living on a scale of 100 points, were significantly improved compared with preoperative values, from 30 to 99 points and 0 to 60 points, respectively. Indications for arthroplasty for neuropathic arthropathy should be carefully considered in each individual case. In this case, the patient had neuropathic arthropathy in multiple joints; however, TKA was performed because recovery of function in the right knee was expected to significantly improve the patient's activities of daily living, and a good mid-term clinical outcome was achieved. Therefore, indications for arthroplasty should be considered in patients with systemic neuropathic arthropathy such as leprosy, and with accurate assessment and appropriate implant selection, good long-term outcomes may be expected.

Neurogenic osteoarthropathy in leprosy.

According to World Health Organization (WHO), the global registered prevalence of leprosy at the beginning of 2006 stood at 219,826 cases. Pockets of high endemicity still remain in some areas of Africa, India, and Brazil. One of the joint manifestations of leprosy are the signs of Charcot's disease. Charcot's disease of leprosy advanced in spite of the treatment. The different clinical types are sometimes a problem in diagnosis. We report herein two cases.

Results of arthrodesis in neuropathic feet.

We describe the results of arthrodesis for the treatment of recurrent acute neuropathic bone disease in 24 feet and of chronic disease with deformity in 91 feet, undertaken between January 1984 and December 2003. All were due to leprosy. Correction of the deformity was achieved in 80 of 106 feet (76%) and fusion in 97 of 110 feet (88%). In the 24 feet in which recurrent neuropathic bone disease was the reason for surgery, 17 (71%) obtained stability while in seven (29%) symptoms recurred postoperatively. Complications were experienced following 58 of the 110 operations (53%). In patients presenting primarily with deformity with a minimum follow-up of two years (79 feet), there was a reduced frequency of ulceration in 40 (51%). Normal footwear could be worn by 32 patients (40%) after surgery, while 40 (51%) required a moulded insole. Arthrodesis of the ankle in the neuropathic foot due to leprosy has a good overall rate of success although the rate of complications is high.

The often overlooked digital tuft: clues to diagnosis and pathophysiology of neuropathic disease and spondyloarthropathy.

OBJECTIVE: To assess diagnostic implications of abnormalities of the pedal digital tufts and to identify features to facilitate distinguishing of spondyloarthropathy and leprosy. BACKGROUND: Better criteria for distinguishing between these disorders are necessary if their character, natural history, and evolution are to be understood. METHODS: Pedal x rays of 91 consecutive patients with diabetes, 21 alcoholic patients, 100 with spondyloarthropathy, 8 with scleroderma, and 137 with leprosy, and 188 defleshed skeletons of individuals with alcoholism, syphilis, cerebrovascular disease, and paraplegia from the Terry and Hamman-Todd collections were examined for evidence of osseous and articular pathologies. Digital tuft abnormalities were divided into irregularity, divot, flattening, resorption, whittling, and fragmentation. RESULTS: Tuft divots were more common in alcoholics than in diabetic, and were more common in both than in the other groups studied. Tuft flattening was limited to alcoholic and neurosyphilis groups. Tuft whittling was especially prominent among individuals with spondyloarthropathy, contrasted with leprosy and diabetes. Aligned fractures were more common in diabetics than individuals with leprosy. Misaligned fractures were limited to individuals with leprosy and neurosyphilis. Leprosy and spondyloarthropathy were complicated by phalangeal and metatarsal whittling more commonly than other diseases studied. Background pedal abnormalities, derived from individuals with cardiovascular syphilis, cerebrovascular accidents, and paraplegia, was limited to abnormal divots only. CONCLUSIONS: Pedal digital tufts undergo a variety of pathological alterations useful in the recognition of disorders traditionally considered neuropathic in aetiology and in distinguishing differential considerations. Tuft flattening appears specific for alcoholism and neurosyphilis, and misaligned fractures seem specific for neurosyphilis and leprosy, providing differential assistance related to spondyloarthropathy. Conversely, periosteal reaction distinguishes spondyloarthropathy from leprosy.

The Charcot foot

Sr - Agnès Hartemann-Heurtier and colleagues (Nov 30, p 1776) conclude that one consistent finding Charcot foot is "dysfunction of the autonomic nervous system".....

Charcot joint-like changes following ankle fracture in a patient with no underlying disease: report of a rare case.

Charcot joint is a disease that often occurs in patients with diabetes mellitus, tabes dorsalis, syringomyelia, chronic alcoholism, leprosy, trauma, or infection after fractures and dislocations. The treatment for Charcot joint has various complications, such as skin lesions, infections, and delayed union. We present our experience with a male patient who developed Charcot joint-like changes without diabetes mellitus or any other disease after an ankle fracture due to minor trauma.

Charcot joint-like changes following ankle fracture in a patient with no underlyng disease: report of a rare case

Charcot joint is a disease that often occurs in patients with diabetes mellitus, tabes dorsalis, syringomyelia, chronic alcoholism, leprosy, trauma, or infection after fractures and dislocations. The treatment for Charcot joint has various complications, such as skin lesions, infections, and delayed union. We present our experience with a male patient who developed Charcot joint-like changes without diabetes mellitus or any other disease after an ankle fracture due to minor trauma.

Neuropathic osteoarthropathy: diagnostic dilemmas and differential diagnosis.

The purpose of this pictorial essay is to illustrate the radiologic spectrum of imaging findings of neuropathic osteoarthropathy. Typical findings include joint destruction, disorganization, and effusion with osseous debris. A variety of other imaging findings related to neuropathic osteoarthropathy such as resorption of the ends of tubular bones and neuropathic fracture are shown. The two prevailing theories for the pathophysiology of neuropathic bone and joint disease, the neurovascular and neurotraumatic theories, are briefly described. Examples of osteoarthropathy from diverse causes are presented including syringomyelia, spinal cord injury, meningomyelocele, diabetes mellitus, congenital insensitivity to pain, steroid injections, syphilis, leprosy, and others. The discussion focuses on key imaging features with emphasis on disease patterns and differential diagnosis, which vary by skeletal location.

Neurogenic arthropathy. Differential diagnosis.

Neurological affections responsible for secondary arthropathic pathology are: tabes, syringomyelia, diabetes mellitus, congenital insensitivity to pain syndrome, alcoholism, leprosy. Each of the affections shows predilection for specific joints: syringomyelia the shoulder, tabes the hip and knee, diabetes mellitus the foot, congenital insensitivity to pain the lower limb, alcoholism the shoulder and knee. The authors discuss two cases of hip arthropathy in previous dorsal myelic fractures.

The results of arthrodesis of the ankle for leprotic neuroarthropathy.

Twenty-four patients who had arthrodesis of one or both ankles for leprotic neuroarthropathy were followed for an average of nine years and five months. At operation, after the removal of cartilage, joint debris, and sclerotic bone, the ankle joint was transfixed with a Küntscher intramedullary nail, and staples or Kirschner wires were used to control rotation. Fusion of bone was obtained in nineteen (73 per cent) of the twenty-six ankles. Failure to obtain fusion was due to postoperative infection in four patients, deficiency of the site of arthrodesis in one patient, and refracture through the site of fusion in two patients. When arthrodesis was successful, additional neuroarthropathic destruction of the mid-tarsal joint was halted, and the preoperative clinical symptoms of dull pain, local warmth, swelling, and instability were relieved.

Arthropathy of the wrist in leprosy--what changes are caused by long-standing peripheral nerve palsy?

A radiographical screening study of 338 leprotic patients was performed. Clinically, according to a nerve score (NS) designed by us, 12.9% of 674 hands showed mild nerve palsy (NS 5 or 6), 75.9% moderate (NS 3 or 4), and 11.4% severe (NS less than 2). Twenty-nine hands of 26 patients (NS 4.2 on average) demonstrated abnormal changes of the wrist joint on radiographs. We classified them into four groups: (a) lunate collapse (four patients), (b) scaphoid nonunion (eight), (c) scaphoid cyst (three), and (d) trapezium OA (11). In the lunate collapse and the scaphoid nonunion groups, destructive and reconstructive changes as described by Eichenholtz were identified on plain film. These groups demonstrated remarkable instability of the stress and dynamic roentgenograms. In contrast, the scaphoid cyst and trapezium OA wrists showed neither fracture nor instability and fewer changes than the other two groups. We considered the destructive changes that had taken place in the lunate collapse and the scaphoid nonunion wrists to be neuroarthropathy due to long-standing nerve palsy.

Neuroarthropathy of the foot in leprosy.

Among 449 patients with leprosy, 40 had clinical and radiographic evidence of neuroarthropathy in 50 feet. These changes were classified into four types according to the joints first involved by major lesions: ankle (25 feet), midtarsal (15 feet), tarsometatarsal (7 feet) and subtalar (3 feet). The progression of joint destruction was different in each type, but despite the severe destructive changes seen in radiographs, the patients had relatively few complaints. The muscles innervated by the peroneal nerve were severely paralysed in ankle and midtarsal types and it seems that, over a long term, repeated trauma and/or abnormal stress may lead to these types of neuroarthropathy. Neuropathy was less severe in the tarsometatarsal type of joint degeneration; the pathogenesis in this type seemed to be mainly direct trauma to the forefoot.

Acquired flatfoot in adults.

The main causes of the acquired flatfoot deformity in adults are reviewed. This condition can be extremely disabling; however, careful analysis combined with thoughtful conservative management or surgical treatment can usually enable the patient to maintain a functional level.

Radiological changes in serial x-rays of the foot and tarsus in leprosy.

Most bone abnormalieis seen in serial films of the feet in leprosy were static being the end result of old disease. Changes over a period of time were observed in serial fims of 214 feet and these changes were due to a combination of infection, neuropathic changes and avascular necrosis occurring in anaesthetic feet. The bone abnormalities seen were absorption of toes and metatarsals; bone destruction; a neuropathic arthropathy of toes and metatarsals and various patterns of tarsal disintegration.