The Role of Bone Scintigraphy with SPECT/CT in the Characterization and Early Diagnosis of Stage 0 Charcot Neuroarthropathy.

Raju Ahluwalia,Prashanth Vas,Nina Petrova,Chris Manu,Michael Edmonds,Nicola Mulholland,Ben Corcoran,Ahmad Bilal,Krishna Boddhu,Gill Vivian,Ines Reichert,Maureen Bates,Venu Kavarthapu

doi:10.3390/jcm9124123

Abstract

We describe the use of Single Photon Emission Computed Tomography/Computed Tomography (SPECT/CT) in the investigation and diagnosis of Charcot neuroarthropathy (CN) in patients with a hot swollen foot but normal radiographs and clinical suspicion of CN, usually termed Stage 0. This was a retrospective cohort review of 46 diabetes patients who underwent 3 phase bone scintigraphy with “High Resolution” SPECT/CT. The imaging demonstrated that Stage 0 Charcot foot has a distinct bone pathology, which can be classified into three groups: (1) fractures on Computed Tomography (CT) with accompanying focal uptake of tracer on SPECT, (2) bony abnormalities apart from fracture on CT with focal uptake of tracer on SPECT, and (3) normal CT but focal bony uptake of tracer on SPECT. The CT component of SPECT/CT detected bony fractures in 59% of patients. Early treatment with below knee cast and follow-up for 24 months showed only 4 patients who developed Stage 1 Eichenholtz Charcot foot. Our findings support the use of 3 phase bone scintigraphy with SPECT/CT in the characterization and early diagnosis of CN. Stage 0 Charcot foot has a distinct bone pathology which requires urgent treatment to prevent progression to Stage 1 Eichenholtz Charcot foot. If SPECT/CT is unavailable, CT alone will detect bone fracture in 59% patients.

Highlights

Charcot neuroarthropathy (CN) is a condition affecting the bones, joints, and soft tissues of the foot and ankle, characterized by inflammation in the earliest phase [1]
The inclusion criteria consisted of people with diabetes (Type 1 or Type 2), who presented to the Multidisciplinary Diabetic Foot Clinic between 2010 and 2013 with an acute hot swollen foot but with intact skin and with radiographically normal bones and joints
The results of the bone scintigraphy with SPECT/Computed Tomography (CT) scans were classified into three groups and individual details pertaining to the unilateral hot swollen foot are presented in Table 1, Table 2, and Table 3

Summary

Introduction

Charcot neuroarthropathy (CN) is a condition affecting the bones, joints, and soft tissues of the foot and ankle, characterized by inflammation in the earliest phase [1]. In its severest form CN can lead to deformity, ulceration, infection, and amputation. It contributes to significant morbidity and premature mortality and has a negative impact on the activities of daily living [1]. A characteristic early presentation in diabetes is the hot swollen foot often when radiographs are still normal. This is the recognized Stage 0 Charcot foot [5,6,7]. The previous use of three-phase bone scintigraphy in diabetes patients with neuropathy suggested increased blood flow to bone but the planar imaging has low anatomical resolution [9]. Combining SPECT and CT considerably increases bone scan image quality (attenuation correction), anatomic localization and diagnostic accuracy [11]

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