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Inflammatory Osteolysis in Diabetic Neuropathic (Charcot) Arthropathies of the Foot

DR Sinacore, PT, PhD, FAPTA, is Associate Professor, Department of Medicine and Program in Physical Therapy, and Director, Applied Kinesiology Laboratory, Campus Box 8502 Washington University School of Medicine, 4444 Forest Park Blvd, St Louis, MO 63108 (USA)
MK Hastings, PT, DPT, ATC, is Assistant Professor, Program in Physical Therapy and Department of Orthopaedic Surgery, Washington University School of Medicine
KL Bohnert, MS, CDT, is Research Coordinator and Certified Densitometry Technologist, Applied Kinesiology Laboratory, Program in Physical Therapy, Washington University School of Medicine
FA Fielder, RN, APRN, BC, is board-certified Adult Practice Nurse, Foot and Ankle Service, Department of Orthopaedic Surgery, Washington University School of Medicine
DT Villareal, MD, is Associate Professor, Department of Medicine, Washington University School of Medicine
VP Blair III, MD, is Private Practice Associate, West County Bone and Joint Associates, St Louis, Missouri
JE Johnson, MD, is Associate Professor, Department of Orthopaedic Surgery, Chief, Foot and Ankle Service, Washington University School of Medicine

Address all correspondence to Dr. Sinacore at: sinacored{at}wustl.edu

Objective: Osteolysis and low bone mineral density (BMD) are underappreciated consequences of several chronic diseases that may elevate the risk for fracture. The purpose of this study was to assess tarsal BMD associated with acute inflammation (ie, inflammatory osteolysis) in individuals with chronic diabetes mellitus (DM), peripheral neuropathy (PN), and recent-onset neuropathic (Charcot) arthropathy (NCA) of the foot.

Research Design and Methods: This was a case-control study of 32 people (11 men, 21 women) with DM, PN, and NCA of the foot or ankle. The subjects with DM, PN, and NCA were compared with 64 age-, sex-, and race-matched control subjects (24 men, 40 women) without DM, PN or NCA. Within the first 3 weeks of cast immobilization, BMD was estimated in both calcanei using quantitative ultrasonometry. Acute inflammation was confirmed by comparing skin temperature differences between the feet of the subjects with DM, PN, and NCA and the feet of the control subjects.

Results: Skin temperature differences averaged 6.7°F (SD=4.0°F) (involved foot minus noninvolved foot) in the feet of the subjects with DM, PN, and NCA compared with 0.0°F (SD=1.3°F) in the feet of the control subjects. Calcaneal BMD averaged 384 mg/cm² (SD=110) in the involved feet and 467 mg/cm² (SD=123) in the noninvolved feet of the subjects with DM, PN, and NCA and 545 mg/cm² (SD=121) in combined right and left feet of the control subjects.

Conclusions: Inflammation in individuals with DM, PN, and NCA may contribute to or exacerbate a rapid loss of BMD. Inflammatory osteolysis may be a prominent factor responsible for both the spontaneous onset of neuropathic fracture and the insidious and progressive foot deformity that is the hallmark of the chronic Charcot foot.

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