Cases reported "Arthropathy, Neurogenic"

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1/11. Neuropathic arthropathy of the elbow. A report of five cases.

    BACKGROUND: Neuropathic arthropathy of the elbow is rare and characterized by a painless but unstable articulation. The functional capacity of patients with this condition has not been reviewed in detail. methods: Five male patients, with an average age of fifty-one years, were treated for neuropathic arthropathy of the elbow. The underlying conditions associated with the arthropathy included syringomyelia, insulin-dependent diabetes mellitus, end-stage renal failure, and two cases of polyneuropathy of unknown cause. Four patients sought medical attention after a specific traumatic event. Peripheral sensory and motor dysfunction was present in each patient. Radiographs of the elbow revealed dislocation, fracture fragmentation, and heterotopic ossification. Our management of the neuropathic elbows centered on maintenance of a functional arc of motion through physical therapy aimed at regaining muscle strength and the use of orthoses for support. Operative treatment was performed for an associated ulnar or radial nerve compression syndrome in three patients, and an open reduction and internal fixation of an unstable proximal ulnar nonunion associated with loose implants was performed in one. RESULTS: The patients were followed for an average of nineteen months, with a range of twelve to thirty-six months. All patients had a pain-free elbow with a functional range of motion at the most recent follow-up examination, and none wished to have further treatment. The operatively treated ulnar nonunion united successfully. All three patients treated surgically for an associated nerve compression syndrome had recovery of nerve function. CONCLUSION: In the face of instability and gross distortion of the joint, the patients in this series demonstrated remarkably good function.
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2/11. arthrodesis of the Charcot foot and ankle.

    The unstable Charcot foot remains a challenge to even the most experienced surgeon. Reconstructive surgical management of the neuropathic Charcot foot is a valuable treatment option for the patient who has severe musculoskeletal deformity. Frequently, the unstable nature of this deformity prevents successful use of therapeutic shoes or braces. For these high-risk individuals, reconstructive surgery often is the only way to avoid amputation. With precise surgical technique, appropriate postoperative care, and meticulous patient compliance, stability can be restored to the dysfunctional foot. The management of the Charcot foot can be extremely rewarding for the patient and surgeon.
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3/11. Charcot arthropathy in relation to autonomic dysreflexia in spinal cord injury: case report and review of the literature.

    Charcot spinal arthropathy has been described as a late complication of spinal cord injury. In patients with these injuries in whom the spine below the level of injury is insensate, joint trauma can progress until spinal instability ensues. The authors describe the case of a 50-year-old man with complete C-8 tetraplegia who experienced a 4-month history of episodic severe headaches, profuse sweating over his face and arms, and episodic severe hypertension in addition to a "grinding" sensation in the lower back. Charcot arthropathy at the T11-12 levels with pathological mobility was demonstrated on neuroimaging. Intraoperatively, a complete spinal cord transection was identified. Anterior and posterior thoracolumbar fusion across the mobile segment resulted in complete amelioration of signs and symptoms of autonomic dysreflexia. This entity, a common condition in the setting of spinal cord injury, has many triggers. Definitive treatment is targeted at the removal of the underlying cause. As demonstrated here, Charcot spinal arthropathy can act as a powerful trigger for induction of autonomic dysreflexia. Treatment of the associated spinal instability resulted in eradication of all signs and symptoms of the dysreflexia.
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4/11. Charcot's disease of the spine: diagnosis and treatment.

    STUDY DESIGN: Retrospective study. OBJECTIVE: To report nine cases of Charcot's joint of the spine, to clarify the difficulty in diagnosis and treatment, and to analyze the literature. SUMMARY OF BACKGROUND: Charcot's joint of the spine, also known as spinal neuropathic or neurogenic arthropathy, is a destructive condition that affects the intervertebral disc and the adjacent vertebral bodies. It is the result of a loss of joint protection mechanisms, generally secondary to a spinal cord lesion. We report a series of nine patients treated surgically. methods: Eight men and one woman suffering from paraplegia or tetraplegia were reviewed. The time interval between the neurologic disorder and the diagnosis of neuropathic spinal arthropathy was 10 to 36 years. The most frequent presenting symptom was an evolutive thoracolumbar kyphosis, sometimes associated with back pain or increased spasticity in the lower limbs. The neuropathic arthropathy involved the thoracic spine in four patients and the lumbar spine in four other patients. The remaining patient presented two arthropathies, one thoracic and one lumbosacral. A percutaneous vertebral biopsy was performed in five patients suspected to have an infection or a tumor. Treatment was always surgical. In eight cases, a circumferential fusion was performed in the area of the dislocated vertebral levels. The postoperative follow-up was from 3 years to 10 years. RESULTS: A solid and stable circumferential fusion of the spine was obtained in all patients. The functional status improved in all patients. Pain and sagittal imbalance were successfully treated. The increased spasticity observed at the initial examination improved in all patients who returned to the neurological deficit initially present before the onset of Charcot's arthropathy. CONCLUSIONS: The diagnosis of Charcot's arthropathy of the spine must be considered in paraplegic and tetraplegic patients with spinal deformity with bone destruction and vertebral dislocation in the absence of an infection or neoplastic disease. The treatment of a Charcot's spine is circumferential fusion and osteosynthesis. Monitoring by clinical and imaging examination must be continued, because multifocal vertebral lesions can occur in cases of extensive proprioceptive deficit.
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5/11. Neuropathic elbow arthropathy: a review of six cases.

    Neuropathic arthropathy, also known as Charcot arthropathy, of the elbow joint is a rare and progressive joint disorder with little available information in the literature. Presentation and treatment data on 6 patients with this pathology are reviewed. In addition, outcome data are presented on all 6 patients at a mean follow-up of 51 months. Three of these patients had undergone surgical procedures for the treatment of their pathology. At the time of their latest follow-up, 2 patients had died but reported good pain relief and functional range of motion before their deaths. At a mean follow-up of 63 months, the remaining 4 patients also had minimal pain. Of these 4 patients, 3 reported moderate to gross instability in their elbows. Nevertheless, all 4 patients had good functional use of their arms with a mean Mayo Elbow Performance Score of 91. Our data suggest that surgical treatment of appropriate patients does not necessarily preclude a successful outcome. However, surgical treatment was also associated with an unpredictable course and a high rate of complications. Therefore, most patients with this pathology should be treated with nonoperative methods, and routine surgical intervention should be avoided.
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6/11. Treatment of Charcot spinal arthropathy following traumatic paraplegia.

    Four cases of Charcot's spinal arthropathy in patients with complete traumatic paraplegia were diagnosed an average of 12 years (range, 4-22 years) postinjury. Each patient had previous posterior spinal fusion with Harrington instrumentation. The Charcot joint occurred just below the fusion near the thoracolumbar junction and well below the level of spinal cord injury. All four patients experienced progressive kyphosis, flexion instability, and loss of height. Each underwent a treatment protocol that included anterior fusion with partial resection of the Charcot joint and staged posterior spinal fusion and stabilization with Cotrel-Dubousset (CD) rods. At follow-up evaluation 18-30 months postoperatively, three of four patients showed complete healing with kyphosis correction. One patient developed loosening of his lower hooks at 6 months postoperatively and required posterior revision with ultimate healing. Resection of the involved segments along with two-stage fusion with segmental instrumentation provides excellent management of this difficult problem.
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7/11. The results of arthrodesis of the ankle for leprotic neuroarthropathy.

    Twenty-four patients who had arthrodesis of one or both ankles for leprotic neuroarthropathy were followed for an average of nine years and five months. At operation, after the removal of cartilage, joint debris, and sclerotic bone, the ankle joint was transfixed with a Kuntscher intramedullary nail, and staples or Kirschner wires were used to control rotation. Fusion of bone was obtained in nineteen (73 per cent) of the twenty-six ankles. Failure to obtain fusion was due to postoperative infection in four patients, deficiency of the site of arthrodesis in one patient, and refracture through the site of fusion in two patients. When arthrodesis was successful, additional neuroarthropathic destruction of the mid-tarsal joint was halted, and the preoperative clinical symptoms of dull pain, local warmth, swelling, and instability were relieved.
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8/11. Charcot's spine with neurological deficit: computed tomography as an aid to treatment.

    A patient with Charcot's disease of the lumbar spine presented with weakness of one extremity. Myelographic and x-ray film studies indicated stenosis and compression due to degenerative changes. Although decompression and fusion were considered, computed tomographic scans indicated the wide extent and location of the destructive changes. Nonoperative treatment was elected because of the high risk of fusion failure and instability.
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9/11. Treatment of the neuropathic knee by arthroplasty.

    The neuropathic joint is one of the most difficult management problems in orthopaedic practice. The surgeon is often referred the patient late in the course of the disease, when there has been marked joint destruction so that non-operative measures are not suitable. We report a case of a severely deformed neuropathic knee joint, for which an uncemented total knee replacement was performed. The rationale for use of this procedure instead of arthrodesis, and discussion of the condition follow.
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10/11. Totally implanted direct current stimulator as treatment for a nonunion in the foot.

    Nonunions and delayed unions are postoperative complications with which the podiatric surgeon must be concerned. Although the incidence is infrequent, their treatment methods vary, and can range from bone grafting to internal and external fixation of fragments, arthrodesis, and/or the use of indirect and direct bone stimulation. This manuscript details a case of a nonunion of the first metatarsal cuneiform joint 8 months after attempted Lisfranc's joint fusion for Charcot arthropathy of the midfoot. The nonunion was treated with bone grafting, internal fixation, and the use of an implanted direct current bone stimulator. Although implanted bone stimulators are commonly used for the treatment of failed unions of the posterior spine, tibia, and humerus, to date, the authors submit this is the first reported case of implementing a totally implanted direct current stimulator for treatment of a nonunion in the foot.
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