A plain radiograph does not detect Charcots osteoarthropathy in stage 0.
Date First Published:
June 28, 2007
Last Updated:
July 9, 2007
Report by:
Charlotte Houltram, medical student (Manchester Royal Infirmary)
Search checked by:
Charlotte Houltram, Manchester Royal Infirmary
Three-Part Question:
In a [diabetic patient] with a [hot swollen foot and no visable break to the skin] does [MR imaging or plain radiography have a better clinical utility at diagnosing Charcot's osteoarthropathy?]
Clinical Scenario:
A 45 year old man with diabetes and peripheral neuropathy presents to the emergency department with a hot, red, swollen foot. There is no break in the skin and the patient cannot recall an injury. You suspect Charcot's arthropathy and wonder if plain x-ray or MR Imaging should be your imaging method of choice.
Search Strategy:
(exp diabetes mellitus OR exp diabetic foot) AND (exp magnetic resonance imaging OR MRI.mp. OR exp x-ray OR plain radiograph.mp.) LIMIT to humans AND English language.
Search Details:
Medline 1950 to June 2007 using the Ovid interface and Embase 1996 to week 25 2007.
Outcome:
The search located 70 papers but only 2 of these were relevant.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| The perils of procrastination: effects of early vs. delayed detection and treatment of incipient Charcot fracture Chantelau E 2005 Germany | 11 diabetic patients with incipient Charcot foot (early referral-case group) and 13 patients with overt Charcot foot (late referral-control group) without definite fractures on the first x-ray after onset of symptoms who were referred to foot clinic | Clinical trial | extent of fracture and deformity post- total contact casting | 1/11 case patients developed extended foot fractures and severe deformity, vs 12/13 control patients (P<0.001 | A sample size so small that the level of statistical significance was no reached. There was no blinding. |
| Evaluation of the Diabetic Foot by MR Imaging or Plain Radiography- an Observational Study Chantelau E, poll LW 2006 Germany | 26 diabetic patients with peripheral neuropathy and a diagnosis of Charcot's foot. | observational study | blinded assessment of MR Images and x-ray films for type and frequency of injuries | In stage 0 MRI showed advanced stress bone injuries, oedema of the adjacent soft tissues and joint effusion, x-ray, by contrast did not show any of these abnormalities but displayed normal bone anatomy in all 7 feet (P=0.02) | A very small sample size (26 feet in 20 patients) |
Author Commentary:
The cited papers both only have very small patient groups, however this is the best available evidence- larger trials would be difficult to conduct owing to the relatively low prevalence of Charcot's arthropathy. The studies concur that MR Imaging has a better clinical utility at diagnosing Charcot's arthropathy than plain x-ray (which does not detect stage 0 changes) and gives more detail about the stage of the disease process.
Bottom Line:
A patient with the clinical diagnosis of Charcot's arthropathy should undergo MR Imaging of the foot.
References:
- Chantelau E. The perils of procrastination: effects of early vs. delayed detection and treatment of incipient Charcot fracture
- Chantelau E, poll LW. Evaluation of the Diabetic Foot by MR Imaging or Plain Radiography- an Observational Study