Presentation
Foot pain and difficulty walking.
Patient Data
The second toe has been amputated at the level of the metatarsal head. There is extensive dorsal soft tissue swelling containing gas centered on the first metatarsophalangeal joint. Hallux valgus deformity is noted; however, there is relative sparing of the joint space. No erosions or periarticular osteopenia is demonstrated. No soft tissue calcification.
There is joint destruction across the midfoot involving the tarsometatarsal joints suggestive of Charcot's arthropathy; however, there is no obvious Lisfranc joint disruption.
Incidental spurs arise from the posterior and plantar aspects of the calcaneum and the anterior process of the talus. Mild vascular calcification noted.
Conclusion
Soft tissue infection of the dorsal forefoot over the first MTP joint with gas forming organism (necrotizing cellulitis). There is, however, little evidence of septic arthritis or osteomyelitis. Midfoot changes in a diabetic highly suggestive of Charcot arthropathy.
Case Discussion
The classic features of a Charcot joint, several of which are seen here, are (see mnemonic):
- dense bones (subchondral sclerosis)
- degeneration
- destruction of articular cartilage
- deformity (pencil-point deformity of metatarsal heads)
- debris (loose bodies)
- dislocation
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