Tag Archives: Rheumatology
Aside

NEUROPATHIC ARTHRITIS

24 Mar

About The Author

Dr Manoj R. kandoi is the founder president of “Institute of Arthritis Care & Prevention”

an NGO involved in the field of patient education regarding arthritis. Besides providing

literature to patient & conducting symposiums, the institute is also engaged in creating

patients “Self Help Group” at every district level. The institute also conducts a certificate

course for healthcare professionals & provide fellowship to experts in the field of arthritis.

The author has many publications to his credit in various journals. He has also written a

 book “ The Basics Of Arthritis” for healthcare professionals.

The author can be contacted at:

Dr manoj R. kandoi

C-202/203 Navare Arcade

Shiv Mandir Road, Opposite Dena Bank

Shiv mandir Road, Opposite Dena bank

Shivaji Chawk, Ambarnath(E) Dist: Thane Pin:421501

State: Maharashtra Ph: (0251)2602404 Country: India

Membership Application forms of the IACR for patients & healthcare professionals

can be obtained from.

 

Institute of Arthritis Care & Prevention

C/o AshirwadHospital

Almas mension, SVP Road, New Colony,

Ambarnath(W) Pin:421501 Dist: Thane

State: Maharashtra Country: India

Ph:  (0251) 2681457 Fax: (0251)2680020

Mobile ;9822031683

Email: drkandoi@yahoo.co.in

 

Preface:

Studies have shown that people who are well informed & participate actively in

their own care experience less pain & make fewer visits to the doctor than do other

 people with arthritis. Unfortunately in India & many third world countries we do not have patient education & arthritis self management programs as well as support groups. This is an attempt to give a brief account of various arthritis, their prevention & self management methods which can serve as useful guide to the patients of arthritis.

It would be gratifying if the sufferers of the disease knew most of what is given in the book.

 

Acknowledgement\

I am thankful to Dr (Mrs) Sangita Kandoi for her immense help in proofreading & for her invaluable suggestions. The help rendered by  Nisha Jaiswal is  probably unrivalled. Thanks also to vidya, sheetal and  parvati for their continous support throughout the making of the book. The author is grateful to his family for the constant inspiration they offered. The author alone is responsible for the shortcoming in this piece of work. He welcomes suggestions for improvement from the readers.

 

Neuropathic Arthritis:

 

Introduction:

Arthritis caused by repeated minor injuries to the joint which is insensitive to pain leading to its disorganisation is known as neuropathic arthritis. It is named after Jeon-Martin Charcot (1825-1893) who first described it in association with tabes dorsalis.

 

Disorders associated with charcot’s joint:

– Diabetes mellitus                  – Syringomyelia

– Syphilic                                 – Spine bifida

– Chronic alcoholism               – Meningomyelocele

– Hansens disease                    – Congenital insensitivity to pain

– Peripheral nerve injuries        – Amyloid neuropathy

                                                – Charcot -marie -tooth disease

 

Etiopathogenesis:

Reduction in joint sensibility

 

Protective function of pain is lost

 

Loss of protective muscle reflex

 

Harmful joint strain go unprevented

 

Cumulative strains leading to severe degenerative changes

 

Articular cartilage and subchondral bone worn away.

ligament laxity and joint instability.

 

Types of charcots joints:

  1. Atrophic: “Pencil -in -cup” deformation, resorption of bone end, usually affects upper extremities.
  2. Hypertrophic: Joint space narrowing, with bony sclerosis, new periosteal bone formation, articular

      surface fragmentation and joint subluxation can be seen.

 

Stages in formation of charcots joint:

Stage I:             Joint subluxation, osteoporosis, cortical defects.

Stage II:            Osteolysis, fracture, periosteal elevation or new subperiosteal bone formation.

Stage III:          Healing stage, reconstructive, decrease swelling and bony ankylosis.

 

Clinical features:

  • Knee, ankle and subtalar joints are most commonly affected in the lower limb and elbow in upper limits.
  • Joints in the spine may also be affected.

 

Symptoms: Common presenting complaint is painless swelling and instability of joint.

Signs:

  • Irregular hypertrophy at the bone ends
  • Moderate restriction of movements ~
  • Ligament laxity with excessive side to side movements
  • Localized erythema, swelling and increased skin temperature can also be noted.

 

 

Associated findings in charcot’s joints:

In tabes dorsalis, the lower extremities and spine are commonly involved. Other signs include ataxia, argyll robertson pupils, absent knee reflexes and, absent deep position, vibration and pain sense.

In Syringomyelia upper extremities are commonly involved. Clinically features of sensory dissociation, loss of pain and temperature, and preservation of touch is noted. Deep sensation is undisturbed. Progressive muscle atrophy in the arms and fibrillation and trophic changes in the fingers may also be noted.

 

Radiographic changes:

  • Exaggerated changes of degenerative arthritis seen such as loss of cartilage space, absorption of bone ends, hypertrophy of bone at the joints margins etc.
  • Subluxation or dislocation may be noted.

 

Treatment:

Protocol

 
   

 

 

 

 

             Conservative                                                                 Surgicals

          – Supportive and protective                                          – Surgical fusion in corrective

             bracing                                                                          position can be obtained.

           – Role of biphosphate pamidronate

              under investigation.

 

Criteria for surgical intervenation:

  • Instability of the foot or ankle
  • Deformity
  • Chronic ulceration
  • Progressive joint destruction (despite conservative care)
  • Adequate circulation
  • No active infection
  • Systemic factor: Patient should be medically stable and compliant and have the potential for returning to an active lifestyle

 

 

 

Surgical methods used:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Timing of surgical reconstruction / management:

It should be done when stage of reconstruction begins i.e. when acute inflammatory condition has subsided & there is radiographic evidence of healing.

 

Patterns of bone & joint involvement in neuropathic diabetes:

  1. Forefoot: Radiographic findings are often atrophic & destructive mimicking osteomyelitis. Plantar ulceration is an associated findings.
  2. Tarsometatarsal joints: Characterized by disruption of the TMT joints often with collapse of the midfoot. Plantar ulceration frequently develops at the apex of the collapsed cuneiform or cuboid.
  3. Naviculocuneiform, talonavicular & calcaneocuboid joints: There is usually dislocation of the navicular or disintigeration of naviculocuneiform joints.
  4. Ankle joint: Infrequent but associated with severe deformity & instability. It may also be associated with involvement of subtalar joint.
  5. Calcaneus: It is characterized by rare avulsion fracture of the posterior process of the calcaneus.

 

Factors responsible for noninfective bone & joint destruction in diabetic foot:

  • Peripheral neuropathy with loss of protective sensation
  • Autonomic neuropathy with increased peripheral blood flow
  • Mechanical stress of weight bearing ,
  • Repititive trauma
  • Nonenzymatic glycosylation of collagen
  • Decrease cartilage growth activity
  • Corticosteroid -induced osteoporosis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Advertisements