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Imaging of the Charcot Foot
Lee C. Rogers, DPM*, Nicholas J. Bevilacqua, DPM
Amputation Prevention Center at Broadlawns Medical Center, 1801 Hickman Road, Des Moines, IA 50314, USA
Charcot’s foot is a serious problem that causes considerable morbidity and may lead to limb loss. Arriving at a deﬁnitive diagnosis can be challenging. Because of the diﬃculty in diagnosis, one study showed the diagnosis can be delayed on an average of 29 weeks . Given the progressive, destructive nature of Charcot’s arthropathy, this delay can result in advancing deformity, ulceration, infection, and place the limb at risk for amputation. Syphilis has been referred to as the ‘‘great imitator’’ . Charcot’s foot is also an ‘‘imitator.’’ Early on, with a hot, red, swollen foot it is commonly misdiagnosed as cellulitis, deep venous thrombosis, or acute gout. Later, the radiographic bone destruction is often confused with osteomyelitis. Complicating the matter is the fact that infection and Charcot’s arthropathy can coexist in the same extremity. Although clinical signs and symptoms and historical information are crucial, this article focuses on the imaging modalities that can aid practitioners in arriving at an early diagnosis and how to diﬀerentiate Charcot’s arthropathy from osteomyelitis of the feet. The article is divided into sections by imaging modality.
Plain radiography In 1966, American orthopedist Sidney Eichenholtz described a logical and predictable sequence of changes in ‘‘Charcot joints’’ observed by means of serial radiographs. For the purpose of classiﬁcation, he divided these changes into three stages (Table 1). Stage 1 (stage of development) shows debris formation at the articular margins followed by fragmentation of the subchondral bone and capsular distention. Stage 2 (stage of coalescence) is characterized by absorption of ﬁne debris and fusion of large fragments to adjacent bones; the bone ends become sclerotic. Stage 3 (stage of reconstruction) is
* Corresponding author. E-mail address: email@example.com (L.C. Rogers). 0891-8422/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.cpm.2008.01.002 podiatric.theclinics.com
1–3). In 1990. staging. Eichenholtz stage 1 showing fragmentation of the navicular-cuneiform joint (arrow). The diagnosis should be made on clinical presentation consisting of edema. however. Fig. Sanders and Frykberg  described ﬁve diﬀerent anatomic patterns: involvement in the forefoot (pattern 1). swelling. 1. The Eichenholtz classiﬁcation is based solely on radiographic ﬁndings and its lack of clinical correlation is a weakness of the staging system. Shibata described a stage 0. and monitoring Charcot’s foot . and the posterior calcaneous (pattern 5). the ankle joint (pattern 4). Additionally. earlier stage to Eichenholtz’s classiﬁcation. and elevated temperature. This staging system has become widely accepted and is now known as the ‘‘Eichenholtz classiﬁcation’’ (Figs. the naviculocunieform and midtarsal joints (pattern 3).264 Table 1 Eichenholtz classiﬁcation Stage 1 Stage 2 Stage 3 ROGERS & BEVILACQUA Stage of development Stage of coalescence Stage of reconstruction Bone fragmentation Absorption of bone fragments and coalescence to adjacent bone Remodeling and rounding of bone ends characterized by rounding of the bone ends with decrease in sclerosis . Plain radiographs are an important tool. but there is warmth. which includes an early phase consisting of localized heat and swelling. in which there are no radiographic changes noted. . Yu and Hudson  described stage 0 as an acute sprain or fracture in the presence of neuropathy and reviewed the evaluation and treatment of this stage in Charcot’s foot and ankle. also based on radiographic ﬁndings. Shibata and coworkers  reviewed patients who had an arthrodesis of one or both ankles for leprotic neuroarthropathy and added an additional. Sella and Barrette  developed another classiﬁcation scheme. radiographs are inexpensive and universally available and may be used to describe the anatomic pattern of involvement. in detecting. the tarsometatarsal joint (pattern 2). redness. and instability.
IMAGING OF THE CHARCOT FOOT 265 Fig. Eichenholtz stage 3 characterized by rounding of the bone edges and consolidation. The tarsometatarsal joint is the most commonly involved joint . Fig. This biomechanical factor. create a condition conducive to midfoot collapse . 2. Measurement of talar–ﬁrst metatarsal angle may reveal dislocation of the midfoot (Fig. 3. A detailed radiographic analysis of the angular relationships of the bones is necessary and important for monitoring the progression of deformity. Note the absorption of the debris and the sclerosis of the periarticular bone. 1. along with sensory neuropathy and the repetitive trauma of walking. . 4). the calcaneal inclination decreases with equinus at the ankle. Eichenholtz stage 2 in the same patient as Fig. Often. An equinus deformity at the ankle is a key contributor to the collapse at this anatomic level.
it can be helpful. stage 0 Charcot may result in progressive deformity with deleterious eﬀects. and the same molecule may be responsible for calciﬁcation of vascular smooth muscle cells . CT can detect early Fig. This process leads to a decrease in bone mineral density and deposition of minerals (calcium) into the intima media of the arterial wall. 5. Early stages are not as easily recognizable. 5) . Medial calciﬁc sclerosis of the posterior tibial and medial plantar arteries (arrows). CT Although CT has not been advocated in the literature as the diagnostic modality of choice for Charcot’s foot. It is increasingly evident that receptor activator nuclear factor kappa-B ligand is up-regulated in Charcot’s foot causing osteolysis. Physicians need to have a heightened index of suspicion to detect all early Charcot’s feet. Failure to recognize early. An adjunctive ﬁnding to the radiographic bone destruction associated with Charcot’s foot is the presence of medial calciﬁc sclerosis (vascular calciﬁcation) on radiographs. which occurs in up to 90% of cases (Fig. Radiographs should not be relied on to rule out Charcot’s foot. 4. A lateral radiographic view of the foot showing (A) decrease in the calcaneal inclination angle and (B) dislocation and breaking of the talar–ﬁrst metatarsal angle. .266 ROGERS & BEVILACQUA Fig.
Pseudocyst formation may be evident  but can be diﬃcult to distinguish from osteomyelitis. This confusion has led some authors to conclude that Charcot’s foot and osteomyelitis are indistinguishable by MRI . Additionally. 6. it produces an accurate anatomic picture of the extent of the infection.IMAGING OF THE CHARCOT FOOT 267 intra-articular fractures not visualized by plain radiography . Ledermann advocates the use of secondary signs of osteomyelitis. MRI MRI is becoming increasingly popular for the investigation of osteomyelitis in the feet because it has a high sensitivity (77%–100%) [15–17] and speciﬁcity (80%–100%) [15. It is useful for both the diagnosis of osteomyelitis and the preoperative planning of surgical resection. Note the exuberant bone formation and ossiﬁcation of the interosseus membrane. CT is most useful in cases where surgical reconstruction is planned and not necessarily for the diagnosis of Charcot’s foot. which can improve speciﬁcity .18.19] for the disease. 7) . he evaluates the images for adjacent soft tissue defects and tracts with extensions to bone . Hans Peter Ledermann. 6). Charcot’s Fig. who has published a great deal of work on MRI in the diabetic foot. Other clues to consider are that (1) osteomyelitis predominately aﬀects one bone. The addition of three-dimensional computer-generated images may also help in preoperative planning (Fig. Three-dimensional CT of a foot with a previous transmetatarsal amputation and a Charcot’s ankle fused in a plantarﬂexed position. is a proponent of the capability of MRI to diﬀerentiate osteomyelitis from Charcot’s foot. Because over 90% of cases of osteomyelitis are caused by contiguous spread of infection from skin ulcerations. because both produce similar signal changes on MRI. The diﬃculty is distinguishing osteomyelitis from Charcot’s arthropathy. Charcot’s foot and osteomyelitis are characterized by a decrease in intensity in the marrow on T1-weighted images and increased signal intensity on T2weighted images (Fig. .
whereas osteomyelitis more commonly aﬀects the toes and forefoot . radiographs displayed normal bone. and edema of adjacent soft tissue and joint eﬀusion. . (C) Coronal MRI of the midfoot (T2-weighted image) signiﬁcant for marrow edema of the second and third metatarsal shafts (arrow). showed advanced stress injuries and edema in the bone. This study demonstrated the superiority of MRI over radiography for assessing early. more extensive than previous imaging. In stage 0. arthropathy is more commonly diﬀuse. stage 0 Charcot’s foot.268 ROGERS & BEVILACQUA Fig. Chantelau and Poll  compared MRI with plain radiographs in 26 Charcot’s feet of diﬀerent stages. In stages 1 and 2. and (3) Charcot’s foot typically aﬀects the midfoot. (D) Three-phase 99Tc bone scan uncovering activity across the entire tarsometatarsal joint. 7. (A) Dorsoplantar radiograph of a patient with fragmentation at the second metatarsalcuneiform joint (arrow). (B) Coronal CT at the tarsometatarsal scan revealing more fragmentation than visible by plain radiography. MRI conﬁrmed radiographic ﬁndings and in addition showed bone and soft tissue edema. and joint eﬀusion. secondary to stress from previous partial ﬁrst ray amputation. which were not evident on radiographs. In stage 3. but merely conﬁrmed the radiographic ﬁnding in later stages. MRI again conﬁrmed radiographic ﬁndings and additionally noted bone edema that was not visible on radiograph . (2) deformity is common with Charcot’s foot. MRI. but uncommon with osteomyelitis. by contrast.
The blood pool phase is taken several minutes later and can show increased pooling in the soft tissue in the case of inﬂammation. and delayed phases. (C) Increased signal in the lateral ankle/distal ﬁbula noted with 99Tc three-phase bone scan. blood pool. (B) Normal ankle radiograph of the same patient. . and 99m technetium HMPAO ‘‘leukocyte labeled’’ scans. which localizes to osseous tissue to diagnose bone diseases. The delayed image is obtained 3 to 4 hours later and can reveal uptake of Fig. The traditional 99technetium bone scan is highly sensitive for osseous pathology but not speciﬁc (Fig. This section reviews the most common and accessible bone scans. edematous ankle and a rupture bulla at the lateral malleolus.26]. (A) Photograph of a female diabetic patient with an erythematous. Cipro-labeled scans. Its sensitivity can be as high as 100% for osteomyelitis. 111indium scan. including infection. but speciﬁcities range from 25% to 38% [25. 67galium citrate scans. 8. The three imaging phases of the 99Tc bone scan are the blood ﬂow. 8). including traditional 99technetium-labeled scans. There are many types of bone scans.IMAGING OF THE CHARCOT FOOT 269 Bone scintigraphy The term ‘‘bone scan’’ refers to any study where a radiolabel is used. sulfur-colloid marrow scans. The blood ﬂow image is taken within seconds of infusion of the radiolabel and conﬁrms the ﬂow through the macrovasculature.
9. (A) Delayed image of a diabetic patient with a plantar midfoot ulcer. a fourth phase or 24-hour image can be used if there is too much background activity to discern the anatomic location of the increased uptake (Fig. The sensitivity and speciﬁcity for osteomyelitis in the foot are very favorable.6% .6% sensitive and 97. What may be most useful is the ability of 18F-FDG PET to diﬀerentiate osteomyelitis from Charcot’s foot based on the intensity of the metabolism of 18F-FDG. (B) A 24-hour image in the same patient. then reinfused. 99m Tc HMPAO (Ceretec) scans require the white blood cells to be labeled ex vivo. They added that Charcot’s neuroarthropathy did not aﬀect the performance of the scan. 9) . Additionally. leading to the use of hybrid PET-CT where a CT is performed at the same instance and image slices can be compared side-by-side.4% and a speciﬁcity of 96. This makes the scan very useful as a physiologic and functional scan for cancer and other diseases that increase local cellular metabolism and glucose uptake.270 ROGERS & BEVILACQUA the radiolabel in areas of increased bone turnover. Leukocyte-labeled scans are more speciﬁc for osteomyelitis. Poirier and colleagues  reported similar results in 75 patients. there are limited data on the use of PET.29]. 111Indium bone scans are sensitive and speciﬁc for osteomyelitis. The sensitivity for osteomyelitis was 80% and the speciﬁcity was 54% .6% speciﬁc. but may have a lower sensitivity than 99Tc scans. Note the high amount of background tracer. Positron emission tomography There has been an explosion of literature and uses for positron emission tomography (PET) using radiolabeled glucose (18F-FDG). . which sharpened the image considerably. In the diabetic foot. Keidar Fig. One study of 42 patients with diabetic foot infections found a sensitivity of 88. Sensitivities range from 89% to 100% and speciﬁcities from 69% to 80% [28. which is more time consuming. Its limitation has been the poor anatomic resolution. with the scan being 92. Seabold and colleagues  used traditional 99 Tc and 111In scans to diﬀerentiate Charcot’s changes from osteomyelitis in 14 patients with clinically or radiographically diagnosed Charcot’s foot.
In the one remaining patient.35] published two studies (there may be duplication of data in the later study) on the use of PET to Fig.26] 111 In bone scan [28. *It is controversial if MRI can accurately diﬀerentiate Charcot’s foot from osteomyelitis of the feet. 99Tc bone scan. Hybrid PET-CT correctly identiﬁed osteomyelitis in four patients. conﬁrmed infection in soft tissue in ﬁve patients. Clin Podiatr Med Surg 2008. 99mTc HMPAO. PET-CT was able correctly to diﬀerentiate the osseous destruction of Charcot’s arthropathy from osteomyelitis. 111In. 111Indium bone scan. (From Rogers LC. 10. with permission. and ruled out infection in four patients. 99mTc HMPAO leukocyte scan. osteomyelitis.) .25:43–51. Clinical ﬂowchart to guide the choice of imaging modality to aid in the diﬀerentiation of Charcot’s arthropathy or osteomyelitis of the feet.32] 77–100 100 89–100 88–93 % Speciﬁcity 80–100 25–38 69–80 97–98 and colleagues  evaluated 14 patients with suspected foot infection for osteomyelitis. 99 Technitium three-phase bone scan. OM. The diagnosis of Charcot foot. Hopfner and colleagues [34. Bevilacqua NJ.29] 99 mTc HMPAO [31.IMAGING OF THE CHARCOT FOOT 271 Table 2 Sensitivity and speciﬁcity of diagnosing osteomyelitis in the feet by various imaging modalities % Sensitivity MRI [15–19] 99 Tc 3-phase bone scan [25.
(A) Photograph of a male diabetic patient with a plantar cuboid ulcer serving as a portal of entry increasing the likelihood for osteomyelitis.272 ROGERS & BEVILACQUA Fig. but can be complicated by concomitant osteomyelitis. Keidar and colleagues  reported an average standardized uptake value of 5.4. (C) A 99mTc HMPAO ‘‘leukocyte’’ scan. Keidar’s only patient with Charcot’s arthropathy had a standardized uptake value of 1.4–11.8 (0. 11. Hopfner and colleagues found that the standardized uptake value averaged 1.1)  and 1. Summary Making the diagnosis of Charcot’s foot based on imaging is straightforward. and software can detect these variances.5–4.1) in diabetic foot infections. The authors conﬁrmed the lesions surgically and found that 37 (95%) of 39 lesions were identiﬁed successfully using PET. which may make PET a useful tool to diﬀerentiate infection from Charcot’s arthropathy. By contrast.4 (1. osteomyelitis.2 (0. which may diﬀer between the two conditions. the lowest in the study. Table 2 presents all the modalities described previously and reports their usefulness in .5–2. which is negative for osteomyelitis.9)  for Charcot’s foot. glucose metabolism is high in osteomyelitis . (B) Dorsoplantar radiograph in the same patient showing osseous destruction at the midfoot consistent with Charcot’s foot. identify Charcot’s lesions. or both. The ability to diﬀerentiate osteomyelitis from Charcot’s foot lies in the standardized uptake value.
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