Organized chaos? Computed tomographic evaluation of the neuropathic diabetic foot

Accurate radiographic evaluation of diabetic neuroarthropathy is increasingly difficult as the disease becomes more florid. 22 patients with a known diabetic neuroarthropathy of one or both feet were prospectively examined by computed tomography (CT) in the axial and coronal planes. Bilateral changes of a neuroarthropathy were present in 75% of cases. Distinct patterns of disease were seen and categorized into five types in order of increasing severity. Changes at the medial tarsometatarsal joints and adjacent intercuneiform joints were seen in all affected feet. More extensive disease involved the medial arch more commonly than the lateral. Fractures of the tarsal bones were found in 32% of cases and were associated with neuroarthropathic changes in adjacent joints. Calcaneal fractures were seen in four feet. A Lisfranc fracture-dislocation was present in 41% of cases and a bilateral in only 21%. A single CT examination of the foot, while an accurate method of demonstrating the extent of the disease, is an insensitive indicator of disease activity.