Iatrogenic Ankle Charcot Neuropathic Arthropathy after Spinal Surgery: A Case Report and Literature Review

Abstract

Charcot neuropathic arthropathy is a relatively rare, chronic disease that leads to joint destruction and reduced quality of life of patients. Early diagnosis of Charcot arthropathy is essential for a good outcome. However, the diagnosis is often based on the clinical course and longitudinal follow-up of patients is required. Charcot arthropathy is suspected in patients with suggestive symptoms and an underlying etiology. Failed spinal surgery is not a known cause of Charcot arthropathy. Herein we report a patient with ankle Charcot neuropathic arthropathy that developed after failed spinal surgery. A 58-year-old man presented to the emergency room due to painful swelling of the left ankle for 2 weeks that developed spontaneously. He underwent spinal surgery 8 years ago that was associated with nerve damage, which led to weakness of great toe extension and ankle dorsiflexion, and sensory loss below the knee. CT and T2-weighted sagittal MRI showed a fine erosive lesion, subluxation, sclerosis, fragmentation, and large bone defects. Based on the patient's history and radiological findings, Charcot arthropathy was diagnosed. However, the abnormal blood parameters, positive blood cultures, and severe pain despite the decreased sensation suggested a diagnosis of septic arthritis. Therefore, diagnostic arthroscopy was performed. The ankle joint exhibited continued destruction after the initial surgery. Consequently, several repeat surgeries were performed over the next 2 years. Despite the early diagnosis and treatment of Charcot arthropathy, the destruction of the ankle joint continued. Given the chronic disease course and poor prognosis of Charcot arthropathy, it is essential to consider this diagnosis in patients with neuropathy.

Keywords: ankle; charcot neuropathic arthropathy; iatrogenic charcot; spinal surgery.

Figure 1

Left ankle at the time of presentation. There was no abrasion or laceration. The skin overlying the ankle joint was swollen and red.

Figure 2

Initial left ankle X-ray. (A) Anteroposterior, (B) mortise, (C) lateral. Subluxations of the ankle joint and bony fragments were seen. An old healed fracture of the lateral malleolus was also visible.

Figure 3

Initial left ankle: (A) sagittal and (B) coronal computer tomography scans. (A) Multiple bony fragments were scattered in the distal tibia (arrow). (B) The bone density was increased around the ankle and the tibial bone defect had a similar shape to the talar dome (arrowhead).

Figure 4

Initial left ankle T2-weighted coronal magnetic resonance imaging. (A) A cystic mass was seen near the distal fibula (arrow). (B) Joint destruction without bony erosion was seen in the distal tibia. There was no periarticular edema and the bone marrow was normal.

Figure 5

Findings during first arthroscopy. (A) Bony fragments were scattered inside the ankle. joint (arrow). (B) The distal tibial articular surface was unevenly fragmented at the level of the medial talar dome (arrowhead).

Figure 6

Intraoperative findings during the second surgery. A large quantity of fragile, chronic inflammatory tissue was observed around the ankle joint.

Figure 7

Left ankle X-ray. (A) Anteroposterior, (B) mortise, and (C) lateral images acquired 2 months after the final surgery. The images were obtained after removal of the external fixator.

Figure 8

Left ankle X-ray. (A) Anteroposterior, (B) mortise, and (C) lateral images acquired 1 year after the final surgery. The X-ray showed progressive bone collapse but no worsening of alignment.