A Systematic Review of Charcot Neuroarthropathy Misdiagnosis

Abstract

Category: Diabetes; Other Introduction/Purpose: Charcot neuroarthropathy (CN) is a disabling condition of the foot and ankle with a prevalence of up to 13% of patients with Diabetes Mellitus (DM). In the acute phase, CN presents as a hot, swollen foot, with mild destruction of bone and joint structure. If left untreated it can progress to a chronic stage, with bone and joint destruction, presenting with a classic rocker bottom foot deformity. CN is often misdiagnosed in its acute phase; as a result the diagnosis is usually made once CN has progressed to the chronic phase. This delay causes prolonged treatment regimens and poorer outcomes. This systematic review examines the misdiagnosis of CN and the timeline preceding a correct diagnosis. Methods: A review of the literature was performed by searching Ovid Medline, CINAHL, and Scopus for articles published within the last five years that contained the terms Charcot and misdiagnosed, antibiotics, deep vein thrombosis, or osteomyelitis. The database search produced 110 articles, once duplicates were removed. 49 articles were screened out by title and 18 were screened by abstract; leaving 43 eligible articles. During the review of the 43 articles an additional 41 articles were added from references because they provided relevant information. Time of symptom onset to diagnosis was calculated in days, with 30 days counting as one month. Results: In total, 230 patients were included in analysis; of these, 27 (12%) presented with bilateral CN for a total of 257 affected extremities. Type 1 DM was present in 112/210 (53%) of patients, Type 2 DM in 98/210 (47%) of patients, and an unreported DM status in 20/230 (9%) patients. The average time from symptom onset to final diagnosis of CN was 84.8 days, with a range of 25 days to 203 days. Nearly half (110/230; 48%) of the patients experienced CN misdiagnosis. Of these, 99 specific misdiagnoses were reported, with the most common including cellulitis (22/99; 22%), fracture/sprain (18/99; 18%), deep vein thrombosis (13/99; 13%), osteomyelitis (11/99; 11%), and erysipelas and gout (10/99; 10%) each. A total of 42/146 (29%) of patients could recall an incidence of trauma prior to the onset of CN. Conclusion: A diagnosis of CN should be considered in patients with DM who present with peripheral neuropathy coupled with foot swelling, deformity, ulceration, or difficulty ambulating. This literature review has identified that nearly half of patients with CN are misdiagnosed, and many continue to ambulate and do not receive necessary total contact casting until they are correctly diagnosed later on. Subsequently, awareness of CN and the frequency of misdiagnoses associated with it is critical to preventing treatment delay. Further research is necessary to better clarify why CN is so frequently misdiagnosed and the amount of harm that can result from misdiagnoses.

Salvage of Chronic Therapy‐Resistant Bilateral Charcot Foot Osteoarthropathy with Signs of Osteomyelitis

“…The differential diagnosis of Charcot foot is complex and is often misdiagnosed as cellulitis or acute soft‐tissue infection. A systemic review of Charcot neuroarthropathy misdiagnosis reports an 48% misdiagnosis rate in diabetes type I and II patients 6 . We were able to diagnose Charcot arthropathy through the clinical picture, radiograph, and confirmed with the female patient's orthopaedic exam.…”

Pedal acrometastasis secondary to urothelial carcinoma masquerading as Charcot arthropathy in a patient with diabetes

“…Studies have shown that some of the classical features of swelling, erythema and joint effusion may be absent in certain cases 11. It is thus perhaps unsurprising that this particular diabetic complication is in itself frequently misdiagnosed 12. Infection is the most common mimic that requires consideration, but this case highlights the need to maintain a wide differential, including malignancy; misdiagnosis of Charcot arthropathy can have a significant effect on survival 13.…”

Contralateral foot temperature monitoring during Charcot immobilisation: A systematic review

“…The percentage of male participants in studies involving regular temperature monitoring during CN healing ranged from 31.8% 21 to 68.0% 38 (see Table 1). Average age ranged from 50.2 � 6.9 years 32 to 62.5 � 11.7 38 and duration of diabetes ranged from 13 (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25) years 21 to 26.0 years 29,35 and even as high as 38.0 years in T1DM. 38 The percentage of type 2 participants varied from 47.2% 36 to 100.0%.…”

“…There may also be some individuals genetically pre‐disposed to developing Charcot 14 . Charcot remains poorly understood and its early symptoms of swelling, inflammation, and increased skin temperature are often misdiagnosed—in one systematic review, misdiagnoses accounted for 48% of cases 15 . In some instances, delays in diagnosis can be up to 2–3 months in length 16,17 .…”

“…14 Charcot remains poorly understood and its early symptoms of swelling, inflammation, and increased skin temperature are often misdiagnosed-in one systematic review, misdiagnoses accounted for 48% of cases. 15 In some instances, delays in diagnosis can be up to 2-3 months in length. 16,17 Early diagnosis is critical to minimise the risk of deformity, subsequent ulceration, and lower limb amputation.…”