Charcot shoulder and elbow: a review of the literature and update on treatment

Outcomes Following Total Hip Arthroplasty in Patients Who Have Charcot Neuroarthropathy of the Hip

BACKGROUND

Historically, Charcot neuroarthropathy hip (CNH) was deemed a contraindication for total hip arthroplasty (THA). However, as implant design and surgical techniques advance, THA for CNH has been performed and documented in literature. Information regarding the outcomes of THA for CNH is limited. The objective of the study was to assess outcomes following THA in patients who have CNH.

METHODS

Patients who have CNH underwent primary THA and had at least 2 years of follow-up were identified in a national insurance database. For comparison, a 1:10 matched control cohort of patients who did not have CNH was created based on age, sex, and relevant comorbidities. Eight hundred and ninety-five CNH patients who underwent primary THA were compared to 8,785 controls. Medical outcomes, emergency department visits, hospital readmissions, and surgical outcomes including revisions between cohorts were evaluated using multivariate logistic regressions.

RESULTS

The CNH patients were found to have higher risks of 90-day wound complications (P = .014), periprosthetic joint infection (P = .013) (P = .021), dislocation (P < .001) (P < .001), aseptic loosening (P = .040) (P = .002), periprosthetic fracture (P = .003) (P < .001), and revision (P < .001) (P < .001) at 1-year and 2-year follow-up, respectively.

CONCLUSION

While patients who have CNH are at a higher risk of wound and implant-related complications, they are comparatively lower than previously reported in literature. Orthopaedic surgeons should be cognizant of the increased risk in this population to provide appropriate preoperative counseling and enhanced perioperative medical management.

Radiographic Absence of the Left Humeral Head

An older patient with history of surgical decompression for syringomyelia, poor mobility, and frequent falls presented with pain, numbness, and paresthesias in his left upper extremity. Radiograph showed complete absence of the left humeral head. What is the diagnosis, and what would you do next?

Neuropathic arthropathy of the shoulder secondary to operated syringomyelia: a case-based review

Neuropathic arthropathy (NA) is a long-term progressive disorder that causes joint destruction in the existence of a neurologic deficit. Minor injuries and fractures are commonly overlooked until the visible joint deterioration becomes persistent. Syringomyelia is one of the important causes of NA. The appearance of clinical signs in syringomyelia is caused by longitudinal cysts formed in the cervical and cervicothoracic regions of the spinal cord. Depending on the existence of the underlying disorder, the number and localization of the syrinxes, a range of symptoms, involving pain, sensation deficit, loss of motor function, and deep tendon reflex abnormality, emerge. The case is here described of a 68-year-old female patient with shoulder NA following syringomyelia, who partially responded to the rehabilitation program. Furthermore, the available case reports were comprehensively reviewed on Web of Science, Scopus, and PubMed/Medline. Furthermore, the available case reports were comprehensively evaluated on Web of Science, Scopus, and PubMed/Medline. Thus, we aimed to present the demographic characteristics, symptoms, physical examination signs, treatment, and follow-up parameters of syringomyelia-related shoulder NA cases.

Charcot arthropathy of elbow due to syringomyelia: a case series and systematic review of literature

Syringomyelia is an important etiology of Charcot arthropathy of the elbow. We present five interesting patients, along with a systematic literature review summarizing the clinical profile and management of syringomyelia-induced Charcot arthropathy of the elbow. PUBMED, SCOPUS, EMBASE, and Science Direct databases were screened for English articles published between 1980 and 2022 using the search query: "Syringomyelia" AND "elbow" AND ("arthropathy" OR "neuropathic" OR "Charcot"). Articles without full text and/or lack of conclusive evidence of elbow arthropathy due to syringomyelia were excluded. The reference lists of the selected articles were reviewed to identify additional articles describing syringomyelia-induced Charcot arthropathy of the elbow. All five patients in the current series had elbow arthritis with variable motor weakness and dissociated sensory loss. The literature review included 31 reports (45 patients) and five patients from our center (n = 50). The median age at presentation was 45 (13-77) years. The median duration of arthropathy was 24 (0.5-180) months. Thirty-three patients had isolated elbow arthropathies. The other joints affected included the shoulder (n = 13), wrist (n = 7), metacarpophalangeal joints (n = 3), and interphalangeal joints (n = 1). Chiari malformations were present in 33 (66%) patients. Sensory deficits, motor deficits, and ulnar neuropathies were described in 36 (72%), 31 (62%), and 14 (28%) patients, respectively. Surgical decompression for syringomyelia was performed in 13 (26%) patients. The presence of dissociated sensory loss, with or without motor weakness, is key to the suspicion of syringomyelia-induced Charcot arthropathy of elbow. Chiari malformation and ulnar neuropathy are frequently associated with this condition. Key Points • Charcot arthropathy of elbow is not so uncommon as believed • Syringomyelia is an important etiology of Charcot arthropathy of elbow • Therefore, all patients with elbow arthropathy of unknown etiology must be evaluated for dissociative sensory loss • Chiari malformation and ulnar neuropathy are commonly associated with syringomyelia-induced Charcot arthropathy of elbow joint.

A case of neuropathic arthropathy of the elbow with early loosening after total elbow arthroplasty

We reported the case of a 65-year-old woman who presented with neuropathic arthropathy of the elbow and had undergone cervical spinal cord tumour resection at 32 years of age. Open synovectomy with free-body resection was performed; however, the instability of the elbow joint rapidly progressed. Therefore, we performed total elbow arthroplasty using a linked-type prosthesis. However, the humeral stem severely loosened 1 year after arthroplasty. Further, a peri-prosthetic humeral fracture developed due to a minor trauma. Revision total elbow arthroplasty using a long-stem prosthesis was performed 4 years after the primary total elbow arthroplasty. Radiographs taken 2 years after the revision surgery showed no evidence of implant loosening. In this case, early post-operative loosening occurred despite the use of a linked-type prosthesis and an appropriate cementing technique, suggesting that normal implants may not provide sufficient fixation for neuropathic arthropathy of the elbow. Since surgery for neuropathic arthropathy generally has a poor prognosis, surgical interventions including total elbow arthroplasty should be carefully considered.

Neuropathic arthropathy of the shoulder as a presenting feature of Chiari malformation with syringomyelia: a case report with a systematic literature review

BACKGROUND

Neuropathic arthropathy (NA) of the shoulder is a chronic progressive process characterized by joint destruction in the presence of a neurosensory deficit. Syringomyelia, a spinal cord disease, is the leading cause of NA in the upper extremity.

OBJECTIVE

We present a systematic review of NA with syringomyelia cases alongside a case report of an adult with NA of the shoulder that occurs a few 4 years after a revelation and surgical management of a Chiari malformation with syringomyelia.

METHODS

A systematic review was conducted following PRISMA guidelines. A PubMed, Scopus, Isiknowledge, and manual search through references of relevant publications were used to identify all published case reports of NA. Data were collected from each case report on patient characteristics.

RESULTS

The systematic review identified 56 publications and 85 patients (including ours): nearly the same number of males (n = 41) and females (n = 44). The mean age was 50,69. Presentations included reduction of mobility (n = 66), swelling (n = 61) and sensory disorder (n = 63). The pain was absent in 41 cases. In the majority of reported cases 56 (65.1%), syringomyelia was revealed by neuropathic arthropathy, and eleven patients (12.9%) had a history of syringomyelia. Treatment was categorized into non-operative management (37[43.5%]), operative management (27[31.7%]). Following-up was non-reported in 31 (36%) cases. Improvement was reported more with patients who underwent a surgical approach than medical one 28.5% versus 8.1%.

CONCLUSION

Physicians need to be more aware of this destructive joint disease, rare, and often misdiagnosed. Also, it is imperative to integrate clinical, pathological, and imaging findings for accurate diagnosis and for delivering appropriate therapy.

Case series on the Charcot neuroarthropathy in hands after cervical central cord syndrome

Background

Charcot neuroarthropathy (CNA) of the upper extremity occurs most frequently in shoulders. However, CNA in the hands is uncommon and seldom be reported. The onset of CNA is usually insidious. If this process continues undetected, it can result in joint deformity, ulceration and/or superinfection, loss of function, and amputation or even death. In this article, we are going to present three cases of CNA in the hands of individuals with cervical spinal cord injury (SCI) with central cord syndrome.

Case presentation

Three male individuals with cervical spinal stenosis contracted tetraplegia (American Spinal Injury Association Impairment Scale Grade D, D, and B) due to spinal cord contusion after a trauma and developed hand swelling without pain 2 to 3 months after their SCI. X-ray showed degenerative joint changes in the hands. CNA was considered due to the patient’s history of cervical SCI, loss of motor function and sensation, symptoms of painless swelling, physical examination, and X-ray findings. The self-care sub scores of Spinal Cord Independence Measure III improved slightly only during rehabilitation and follow-up due to poor hand function.

Conclusions

CNA may develop after a central or peripheral neurological disorder. Nearly every joint of the body can be affected and the lower limbs are the most frequently involved. However, CNA of the hand is rare. We present three patients with CNA in the hands after cervical SCI and review the features and early differential diagnosis of CNA. Currently there is no specific treatment available. Therefore, early identification of CNA and adequate protection to the affected joints seem important.

Rapid Spontaneous Total Fusion of Neuropathic Arthropathy of the Wrist After Limited Intercarpal Arthrodesis: A Case Report and Brief Literature Review

Background

Previous reports on the treatment of neuropathic arthropathy of the wrist were generally conservative, with few case reports of treatment with osteoarticular surgery.

Case Presentation

A 25-year-old right-handed male complained of unpainful swelling of the dorsal aspect of his right wrist for 3 years. He was at that time diagnosed with synovitis and radiocarpal arthritis. The patient underwent a partial Four-Corner Arthrodesis and Synoviectomy to preserve motor function. Over the next 2 months, his right wrist also developed painful redness, with progressive swelling and stiffness. Rheumatoid arthritis, tuberculosis arthritis, and infectious diseases were ruled out in this case. Magnetic resonance imaging (MRI) indicated that he had Chiari II syringomyelia so the patient was eventually diagnosed with destructive neuropathic arthropathy (syringomyelia). After 2 months of conservative treatment, the patient’s right wrist spontaneously and completely fused and the pain disappeared.

Conclusion

Neuropathic arthropathy of the wrist is a rare but clinically significant disease due to its effect on the function of the active limb. Surgeons should rule out a diagnosis of it when treating patients with wrist swelling and osteoarticular abnormalities, otherwise, limited intercarpal arthrodesis should not be taken as a treatment option. Inappropriate partial surgery is likely to lead to rapid total fusion of neuropathic arthropathy of the wrist.

Cervical spondylotic myelopathy with syringomyelia presenting as hip Charcot neuroarthropathy: A case report and review of literature

BACKGROUND

Charcot neuroarthropathy (CN) is a systemic disease characterized by progressive bone loss and destruction, which is usually closely related to diabetes, HIV, etc. However, CN caused by syringomyelia accounts for only 5% of CN cases; the shoulder and elbow are most often involved, and the hip joint is rarely affected. As a rare factor, cervical spondylotic myelopathy (CSM) can be associated with syringomyelia, which is scarcely reported in the literature. Here, we present the first case report to date of CN of the hip caused by syringomyelia secondary to CSM.

CASE SUMMARY

We describe a 76-year-old male patient who was diagnosed with CSM due to neck pain and weakness of limbs 16 years ago. Four years ago, he noticed recurrent swelling of the right hip with pain and was diagnosed with degenerative arthritis. Recently, however, his symptoms gradually worsened, and because of progressive pain, destabilization and weakness of the right hip, he was admitted to our hospital. Through systematic physical, radiographic and laboratory examinations, we finally reached a diagnosis: CN of the right hip associated with syringomyelia secondary to CSM. After comprehensive evaluation of the patient's condition, we performed right total hip arthroplasty. During the follow-up, the patient felt well clinically and could walk independently with a knee brace.

CONCLUSION

We suggest a possible etiological association between CSM and syringomyelia, which may reflect a potential pathogenesis of CN. We encourage clinicians to actively carry out a detailed medical history and comprehensive physical and imaging examinations in patients with joint lesions, especially chronic shoulder neck pain, to rule out the possibility of this association, which plays a crucial role in the early diagnosis of CN. Arthroplasty may no longer be an absolute contraindication to surgical treatment of CN. Reasonable selection of the surgical strategy can markedly improve the clinical symptoms and quality of life of patients.

Rotation-hinged knee prosthesis for the treatment of Charcot arthropathy: a case report and literature review

Charcot arthropathy is a type of destructive osteoarthropathy characterized by neurotrophic and sensory disorders. The condition is relatively rare, with an insidious onset, and it is easily misdiagnosed. Total knee arthroplasty (TKA) can cause excessive joint wear, continuous inflammatory stimulation of the prosthesis, postoperative residual cavity, prosthesis loosening and subsidence, peripheral fracture, infection, and other complications. Furthermore, these complications are more likely to occur in patients with Charcot arthropathy because of disease-specific pathological characteristics, when TKA is performed. Therefore, Charcot arthropathy was once a contraindication to TKA. Recently, with the optimization of joint prostheses and the maturity of surgical techniques, more studies have reported successful cases of TKA in patients with Charcot arthropathy. We report a case of Charcot arthropathy in our hospital, and describe the patient’s medical history, clinical symptoms, signs, imaging findings, diagnosis, and the entire TKA process, to explore the TKA strategy and prosthesis selection in a patient with Charcot arthropathy.

Shoulder arthropathy secondary to syringomyelia: case series of 10 patients

PURPOSE

Neuroarthropathy is a progressive joint degeneration secondary to neurological diseases. In the upper extremity, the shoulder is the most exposed, and it is mainly caused by syringomyelia. This condition is rare; therefore, the literature has documented only a few case reports or case series of small groups of patients.

METHODS

We collected data about patients with shoulder arthropathy due to syringomyelia who were treated in our two institutes and collected among members of the Polish Shoulder and Elbow Society. Our analysis was based on epidemiological data, symptoms, and clinical examinations. We also examined the results of diagnostic tests, including-spinal cord MRI and shoulder X-ray, and treatment methods and their effectiveness.

RESULTS

The examined group included 10 women with an average age of 63 years. Of these, nine patients reported pain, seven reported-swelling, and nine reported-weakness. In every patient, diagnosis was confirmed by X-ray of the shoulder with joint degeneration and MRI of the spinal cord with syrinx. Two patients were operated with reverse shoulder arthroplasty; the first one had excellent result-significant active range of motion improvement and reduction of symptoms, and the second one had a good result-pain relief and moderate range of motion improvement. Other patients were conservatively treated, resulting in total or partial symptoms relief but without significant range of motion improvement.

CONCLUSION

Charcot shoulder secondary to syringomyelia was mainly manifested by range of motion limitation, swelling, and pain. Both conservative and surgical treatments could be a good solution. However, if reverse arthroplasty is technically possible, it seems to be the most promising treatment for recovering function.

Neuropathic Glenohumeral Joint Resorption

An 81-year-old woman was evaluated by a physical therapist at a skilled nursing facility 3 days post total knee arthroplasty (TKA). Following the evaluation, the on-call physician was consulted and radiographs were ordered. Radiographs revealed a chronic neuropathic joint with complete resorption of the humeral head and heterotopic ossification at the scapula. J Orthop Sports Phys Ther 2020;50(8):466. doi:10.2519/jospt.2020.9174.

Glenohumeral Osteoarthritis: An Overview of Etiology and Diagnostics

BACKGROUND AND AIMS

Osteoarthritis (OA) is the world's most common joint disease and there is currently no cure. Glenohumeral osteoarthritis (GHOA) accounts for an estimated 5% -17% of patients with shoulder complaints. The etiology of GHOA is multifactorial, and we review the various non-specific and specific risk factors and further sub-classify them into local and systemic factors.

MATERIALS AND METHODS

Data for this review article were identified by searches of MEDLINE, PubMed, and references from relevant articles using search terms such as "glenohumeral," "osteoarthritis," "epidemiology," "etiology," "imaging," and "pathophysiology." Only articles published in English, German, and Finnish between 1957 and 2017 were included.

RESULTS

The prevalence of radiological shoulder OA has been estimated to be as high as 16% -20% in the middle-aged and elderly population, but the concordance between structural findings and symptoms seems to be weak, as many of these individuals are asymptomatic. The vast majority of GHOA is related to non-specific factors, namely advancing age, while specific risk factors are commonly found in young patients. Diagnosis of GHOA is made when typical clinical features and defined radiological findings overlap in an individual.

CONCLUSION

Ultimately the determinants of shoulder pain in GHOA remain incompletely understood. Improved understanding of the etiology and diagnosis of GHOA will enable clinicians to better determine which patients will benefit from different treatment modalities, as well as provide new avenues to potential treatments.

Charcot Arthropathy of the Shoulder Joint in a Patient with Guillain-Barré Syndrome: A Case Report

CASE

A 53-year-old woman presented with Charcot arthropathy of the shoulder joint secondary to residual sensory neuropathy of Guillain-Barré syndrome, which was accompanied by swollen shoulder and restricted range of motion of the right shoulder. We performed a reverse shoulder arthroplasty (RSA). The range of motion had improved 15 months postoperatively, and there was no postoperative complication after RSA.

CONCLUSION

Clinicians should be aware that Guillain-Barré syndrome can cause Charcot arthropathy of the shoulder joint. RSA is regarded as a useful treatment, although careful follow-up is needed.

Neuropathic Arthropathy of the Shoulder: A Systematic Review of Classifications and Treatments

BACKGROUND

Neuropathic arthropathy of the shoulder is a chronic progressive process characterized by joint destruction in the presence of a neurosensory deficit. Causes include syringomyelia, syphilis, diabetes, chronic alcoholism, and leprosy, with syringomyelia accounting for the vast majority of upper-extremity Charcot joints. Early presentation of this rare condition includes nonspecific symptoms such as swelling, erythema, sensory symptoms, and decreased functionality, making diagnosis challenging.

METHODS

We systematically reviewed 32 case reports published between 1924 and 2016. A total of 59 shoulders from 56 patients are included in this analysis. Variables include patient demographic characteristics, presentation, etiology, diagnostic techniques, treatment, outcome, and follow-up of Charcot shoulder.

RESULTS

We compiled a total of 25 right shoulders (42%), 24 left shoulders (41%), and 10 shoulders (17%) with unspecified laterality. The mean patient age (and standard deviation) was 49 ± 11 years, and the median age was 47 years. There was a higher prevalence in men (37 shoulders [63%]) compared with women (22 shoulders [37%]). Presenting symptoms included reduced range of motion (53 shoulders [90%]), paresthesia or hypoesthesia (45 [76%]), swelling (44 [75%]), weakness (40 [68%]), pain (31 [53%]), and reduction in deep tendon reflexes (22 [37%]). Shoulder radiographs were made in all cases. The presence of a syrinx was detected in 45 shoulders (76%) with magnetic resonance imaging, myelography, or clinical diagnosis. Sixteen shoulders (27%) reported exposure to trauma, with a 69% decrease in time from presentation to diagnosis compared with non-traumatic cases. Treatment was categorized as solely nonoperative management (14 [24%]), operative management (13 [22%]), combined therapy (20 [34%]), and no treatment listed (10 [17%]). Two surgical cases (3%) were excluded from our treatment group analysis as they were treated for unrelated or misdiagnosed conditions.

CONCLUSIONS

Our study increases awareness and understanding of this complex, progressive disease to reduce delay and misdiagnosis and to contribute to the standard-of-care recommendations.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Multiple sclerosis neuropathic arthropathy of elbow: Report of a rare case and literature review

Neuropathic arthropathy (NA) is a progressive degenerative and destructive joint disease associated with underlying chronic neurologic deficit. A 34-year-old woman was referred to our tumor clinic with swelling and destruction of her left elbow joint. Except for a 5-year history of multiple sclerosis (MS), she had no other underlying diseases. Suspected of tumor involvement, she had been undergone an open biopsy. The pathologic report was fibromatosis, which was not compatible with imaging studies and clinical presentations. Second surgical inspection and cellular study didn’t prove tumoral involvement. Magnetic resonance images (MRIs) showed multiple hyper signal plaques in her cervical spine. MRI findings, clinical features, surgical observations, and disproportionate painless elbow destruction all confirmed the MS NA diagnosis.

Common Tumors and Tumor-like Lesions of the Shoulder

Shoulder lesions range from tumor-like lesions such as simple bone cysts to aggressive high-grade sarcomas. The clinical presentation is often nonspecific with shoulder pain as the primary complaint, which may lead to a delayed or missed diagnosis. Delayed diagnosis or a poorly planned biopsy of a malignant shoulder lesion can have a detrimental effect on the patient's prognosis and treatment options. Because the initial patient assessment is crucial for successful treatment, knowledge of the key features of common shoulder tumors and tumor-like conditions can help determine the diagnosis and treatment plan. This article reviews the key features and treatment options of the more commonly encountered benign and malignant shoulder bone and soft-tissue tumors and tumor-like conditions.

Charcot arthropathy of the shoulder joint as a presenting feature of basilar impression with syringomyelia: A case report and literature review

RATIONALE

Charcot arthropathy, also known as Neuropathic arthropathy (NA), is an unusual chronic degenerative disease. To date, there exists a paucity of research on NA caused by syringomyelia.

PATIENTS CONCERNS

A 52-year-old non-diabetic female presented with progressive swelling, pain and limited movement in her left shoulder joint combined with asthenia of her left upper extremity for three months.

DIAGNOSES

Neuropathic arthropathy of the shoulder associated with the cervicothoracic syrinx and basilar impressions was diagnosed.

INTERVENTIONS

The treatment is directed to its potential cause to cease its progression. A posterior fossa decompression (PFD) was conducted for this patient.

OUTCOMES

Postoperatively, the patient's symptoms were relieved and the size of syrinx was reduced at the 6-month follow-up.

LESSONS

Taken together with 34 previous reports identified from a PubMed search, an analysis of 35 cases of Charcot arthropathy was conducted. Surgical decompression is an effective treatment, but the optimal treatment remains controversial. Thus, the aim of this literature review was to remind us to diagnose the potential cause as early as possible and we should spare no efforts on the exploration of etiology and adjuvant therapy for this disease.