Diabetic musculoskeletal complications and their imaging mimics

How to do and evaluate DWI and DCE-MRI sequences for diabetic foot assessment

MRI evaluation of the diabetic foot is still a challenge not only from an interpretative but also from a technical point of view. The incorporation of advanced sequences such as diffusion-weighted imaging (DWI) and dynamic contrast-enhanced (DCE) MRI into standard protocols for diabetic foot assessment could aid radiologists in differentiating between neuropathic osteoarthropathy (Charcot's foot) and osteomyelitis. This distinction is crucial as both conditions can coexist in diabetic patients, and they require markedly different clinical management and have distinct prognoses. Over the past decade, several studies have explored the effectiveness of DWI and dynamic contrast-enhanced MRI (DCE-MRI) in distinguishing between septic and reactive bone marrow, as well as soft tissue involvement in diabetic patients, yielding promising results. DWI, without the need for exogenous contrast, can provide insights into the cellularity of bone marrow and soft tissues. DCE-MRI allows for a more precise evaluation of soft tissue and bone marrow perfusion compared to conventional post-gadolinium imaging. The data obtained from these sequences will complement the traditional MRI approach in assessing the diabetic foot. The objective of this review is to familiarize readers with the fundamental concepts of DWI and DCE-MRI, including technical adjustments and practical tips for image interpretation in diabetic foot cases.

Imaging mimickers of MSK infection

Along with clinical and laboratory findings, imaging has a significant role in the initial evaluation and treatment follow-up of a wide variety of infectious and non-infectious musculoskeletal (MSK) conditions. The imaging findings of many non-infectious MSK processes, such as inflammatory, metabolic, and degenerative arthropathies, complications of diabetes mellitus, osseous and soft tissue injuries, osteonecrosis, tumors, and tumor-like lesions may be nonspecific and often overlap with those found in MSK infections. In this article, the authors discuss the imaging findings of both frequent and rare mimickers of MSK infections, including potential distinguishing characteristics.

Brazilian Society of Angiology and Vascular Surgery 2023 guidelines on the diabetic foot

The diabetic foot interacts with anatomical, vascular, and neurological factors that challenge clinical practice. This study aimed to compile the primary scientific evidence based on a review of the main guidelines, in addition to articles published on the Embase, Lilacs, and PubMed platforms. The European Society of Cardiology system was used to develop recommendation classes and levels of evidence. The themes were divided into six chapters (Chapter 1 - Prevention of foot ulcers in people with diabetes; Chapter 2 - Pressure relief from foot ulcers in people with diabetes; Chapter 3 -Classifications of diabetic foot ulcers; Chapter 4 - Foot and peripheral artery disease; Chapter 5 - Infection and the diabetic foot; Chapter 6 - Charcot's neuroarthropathy). This version of the Diabetic Foot Guidelines presents essential recommendations for the prevention, diagnosis, treatment, and follow-up of patients with diabetic foot, offering an objective guide for medical practice.

Differential Diagnosis of Diabetic Foot Osteomyelitis and Charcot Neuropathic Osteoarthropathy with Deep Learning Methods

Our study aims to evaluate the potential of a deep learning (DL) algorithm for differentiating the signal intensity of bone marrow between osteomyelitis (OM), Charcot neuropathic osteoarthropathy (CNO), and trauma (TR). The local ethics committee approved this retrospective study. From 148 patients, segmentation resulted in 679 labeled regions for T1-weighted images (comprising 151 CNO, 257 OM, and 271 TR) and 714 labeled regions for T2-weighted images (consisting of 160 CNO, 272 OM, and 282 TR). We employed both multi-class classification (MCC) and binary-class classification (BCC) approaches to compare the classification outcomes of CNO, TR, and OM. The ResNet-50 and the EfficientNet-b0 accuracy values were computed at 96.2% and 97.1%, respectively, for T1-weighted images. Additionally, accuracy values for ResNet-50 and the EfficientNet-b0 were determined at 95.6% and 96.8%, respectively, for T2-weighted images. Also, according to BCC for CNO, OM, and TR, the sensitivity of ResNet-50 is 91.1%, 92.4%, and 96.6% and the sensitivity of EfficientNet-b0 is 93.2%, 97.6%, and 98.1% for T1, respectively. For CNO, OM, and TR, the sensitivity of ResNet-50 is 94.9%, 83.6%, and 97.9% and the sensitivity of EfficientNet-b0 is 95.6%, 85.2%, and 98.6% for T2, respectively. The specificity values of ResNet-50 for CNO, OM, and TR in T1-weighted images are 98.1%, 97.9%, and 94.7% and 98.6%, 97.5%, and 96.7% in T2-weighted images respectively. Similarly, for EfficientNet-b0, the specificity values are 98.9%, 98.7%, and 98.4% and 99.1%, 98.5%, and 98.7% for T1-weighted and T2-weighted images respectively. In the diabetic foot, deep learning methods serve as a non-invasive tool to differentiate CNO, OM, and TR with high accuracy.

IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes-related foot infections (IWGDF/IDSA 2023)

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the management and prevention of diabetes-related foot diseases since 1999. The present guideline is an update of the 2019 IWGDF guideline on the diagnosis and management of foot infections in persons with diabetes mellitus. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used for the development of this guideline. This was structured around identifying clinically relevant questions in the P(A)ICO format, determining patient-important outcomes, systematically reviewing the evidence, assessing the certainty of the evidence, and finally moving from evidence to the recommendation. This guideline was developed for healthcare professionals involved in diabetes-related foot care to inform clinical care around patient-important outcomes. Two systematic reviews from 2019 were updated to inform this guideline, and a total of 149 studies (62 new) meeting inclusion criteria were identified from the updated search and incorporated in this guideline. Updated recommendations are derived from these systematic reviews, and best practice statements made where evidence was not available. Evidence was weighed in light of benefits and harms to arrive at a recommendation. The certainty of the evidence for some recommendations was modified in this update with a more refined application of the GRADE framework centred around patient important outcomes. This is highlighted in the rationale section of this update. A note is also made where the newly identified evidence did not alter the strength or certainty of evidence for previous recommendations. The recommendations presented here continue to cover various aspects of diagnosing soft tissue and bone infections, including the classification scheme for diagnosing infection and its severity. Guidance on how to collect microbiological samples, and how to process them to identify causative pathogens, is also outlined. Finally, we present the approach to treating foot infections in persons with diabetes, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and bone infections; when and how to approach surgical treatment; and which adjunctive treatments may or may not affect the infectious outcomes of diabetes-related foot problems. We believe that following these recommendations will help healthcare professionals provide better care for persons with diabetes and foot infections, prevent the number of foot and limb amputations, and reduce the patient and healthcare burden of diabetes-related foot disease.

Diabetes mellitus-related musculoskeletal disorders: Unveiling the cluster of diseases

The current study ushers in a comprehensive review in clinical research to demonstrate the prevalence of musculoskeletal (MSK) complications in diabetes mellitus and the most relevant clinical aspects. In particular, revealing the early symptoms of the disorders, the pathology lurking behind the complications and their optimal management. In diabetes mellitus, MSK complications are common and are largely due to similar pathogenetic factors responsible for the internal organ complications associated with diabetes leading to chronic low-intensity inflammatory processes. MSK disorders develop by vasculopathy, neuropathy, arthropathy or combinations of the above, which are not specific to diabetes. However, their prevalence is significantly increased in diabetes and contributes to the disability impairing patients' quality of life. Locomotor disease affects approximately 34.4-83.5 % of patients suffering from type-2 diabetes mellitus. Several musculoskeletal abnormalities (cheiroarthropathy, Dupuytren's contracture, trigger finger, ect.) can be diagnosed upon physical examination, although certain symptoms (frozen shoulder, neurogenic arthropathy, septic arthritis, etc.) require differential diagnostic considerations. Early identification regarding characteristic symptoms in the treatment reducing inflammation and pain, followed with increasingly strenuous exercise therapy, aligned with optimal management of carbohydrate metabolism, proves essential in alleviating MSK complications.

Non-Enhancing Tissue on Diabetic Foot Magnetic Resonance Imaging in Relation to Osteomyelitis Investigation: Magnetic Resonance Imaging Performance, Pitfalls and Clinical Considerations

Background: Geographic non-enhancing zones in diabetic foot magnetic resonance imaging (MRI) were first described in 2002. No previous report has described the impact and clinical significance of geographic non-enhancing tissue seen in the evaluation of diabetic foot MRI. Purpose: To evaluate the prevalence of devascularization areas on contrast-enhanced MRI in diabetic patients suspected of having foot osteomyelitis, the impact on the performance of the MRI assessment, and the possible pitfalls. Methods: A retrospective study was conducted between January 2016 and December 2017 during which 72 CE-MRIs of 1.5 and 3T were reviewed by 2 musculoskeletal radiologists for the presence of non-enhancing tissue areas and for osteomyelitis. A blinded third party collected clinical data including pathology reports, revascularization procedures, and surgical interventions. The prevalence of devascularization was calculated. Results: Among the 72 CE-MRIs (54 men, 18 women; mean age 64), 28 demonstrated non-enhancing areas (39%). All but 6 patients were found to have been correctly diagnosed on imaging (3 false positives, 2 false negatives, and 1 non-diagnostic). A greater discordance was also observed between the radiological and pathological diagnoses in the MRIs which showed non-enhancing tissue. Conclusion: Non-enhancing tissue is found in a non-negligible portion of diabetic foot MRIs and affects its diagnostic performance when looking for osteomyelitis. The recognition of these areas of devascularization may be helpful for the physician in planning the best treatment option for the patient.

Evaluating the Performance of Pathogen-Targeted Positron Emission Tomography Radiotracers in a Rat Model of Vertebral Discitis-Osteomyelitis

BACKGROUND

Vertebral discitis-osteomyelitis (VDO) is a devastating infection of the spine that is challenging to distinguish from noninfectious mimics using computed tomography and magnetic resonance imaging. We and others have developed novel metabolism-targeted positron emission tomography (PET) radiotracers for detecting living Staphylococcus aureus and other bacteria in vivo, but their head-to-head performance in a well-validated VDO animal model has not been reported.

METHODS

We compared the performance of several PET radiotracers in a rat model of VDO. [11C]PABA and [18F]FDS were assessed for their ability to distinguish S aureus, the most common non-tuberculous pathogen VDO, from Escherichia coli.

RESULTS

In the rat S aureus VDO model, [11C]PABA could detect as few as 103 bacteria and exhibited the highest signal-to-background ratio, with a 20-fold increased signal in VDO compared to uninfected tissues. In a proof-of-concept experiment, detection of bacterial infection and discrimination between S aureus and E coli was possible using a combination of [11C]PABA and [18F]FDS.

CONCLUSIONS

Our work reveals that several bacteria-targeted PET radiotracers had sufficient signal to background in a rat model of S aureus VDO to be potentially clinically useful. [11C]PABA was the most promising tracer investigated and warrants further investigation in human VDO.

IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-related Foot Infections (IWGDF/IDSA 2023)

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the management and prevention of diabetes-related foot diseases since 1999. The present guideline is an update of the 2019 IWGDF guideline on the diagnosis and management of foot infections in persons with diabetes mellitus. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used for the development of this guideline. This was structured around identifying clinically relevant questions in the P(A)ICO format, determining patient-important outcomes, systematically reviewing the evidence, assessing the certainty of the evidence, and finally moving from evidence to the recommendation. This guideline was developed for healthcare professionals involved in diabetes-related foot care to inform clinical care around patient-important outcomes. Two systematic reviews from 2019 were updated to inform this guideline, and a total of 149 studies (62 new) meeting inclusion criteria were identified from the updated search and incorporated in this guideline. Updated recommendations are derived from these systematic reviews, and best practice statements made where evidence was not available. Evidence was weighed in light of benefits and harms to arrive at a recommendation. The certainty of the evidence for some recommendations was modified in this update with a more refined application of the GRADE framework centred around patient important outcomes. This is highlighted in the rationale section of this update. A note is also made where the newly identified evidence did not alter the strength or certainty of evidence for previous recommendations. The recommendations presented here continue to cover various aspects of diagnosing soft tissue and bone infections, including the classification scheme for diagnosing infection and its severity. Guidance on how to collect microbiological samples, and how to process them to identify causative pathogens, is also outlined. Finally, we present the approach to treating foot infections in persons with diabetes, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and bone infections; when and how to approach surgical treatment; and which adjunctive treatments may or may not affect the infectious outcomes of diabetes-related foot problems. We believe that following these recommendations will help healthcare professionals provide better care for persons with diabetes and foot infections, prevent the number of foot and limb amputations, and reduce the patient and healthcare burden of diabetes-related foot disease.

Radiomics method in the differential diagnosis of diabetic foot osteomyelitis and charcot neuroarthropathy

OBJECTIVES

Our study used a radiomics method to differentiate bone marrow signal abnormality (BMSA) between Charcot neuroarthropathy (CN) and osteomyelitis (OM).

METHODS AND MATERIALS

The records of 166 patients with diabetic foot suspected CN or OM between January 2020 and March 2022 were retrospectively examined. A total of 41 patients with BMSA on MRI were included in this study. The diagnosis of OM was confirmed histologically in 24 of 41 patients. We clinically followed 17 patients as CN with laboratory tests. We also included 29 nondiabetic patients with traumatic (TR) BMSA on MRI as the third group. Contours of all BMSA on T 2 - and T1 -weighted images in three patient groups were segmented semi-automatically on ManSeg (v.2.7d). The T1 and T2 features of three groups in radiomics were statistically evaluated. We applied the multi-class classification (MCC) and binary-class classification (BCC) methodologies to compare results.

RESULTS

For MCC, the accuracy of Multi-Layer Perceptron (MLP) was 76.92% and 84.38% for T1 and T2, respectively. According to BCC, for CN, OM, and TR BMSA, the sensitivity of MLP is 74%, 89.23%, and 76.19% for T1, and 90.57%, 85.92%, 86.81% for T2, respectively. For CN, OM, and TR BMSA, the specificity of MLP is 89.16%, 87.57%, and 90.72% for T1 and 93.55%, 89.94%, and 90.48% for T2 images, respectively.

CONCLUSION

In diabetic foot, the radiomics method can differentiate the BMSA of CN and OM with high accuracy.

ADVANCES IN KNOWLEDGE

The radiomics method can differentiate the BMSA of CN and OM with high accuracy.

Imaging of the Diabetic Foot

Diabetic foot complications are increasingly prevalent in the world, leading to significant morbidity and driving up associated health care costs. Complex pathophysiology and suboptimal specificity of current imaging modalities have made diagnosis challenging, mainly in the evaluation of superimposed foot infection to underlying arthropathy or other marrow lesions. Recent advances in radiology and nuclear medicine have the potential to streamline the assessment of diabetic foot complications. But we must be aware of the specific strengths and weaknesses of each modality, and their applications. This review offers a comprehensive approach to the spectrum of diabetic foot complications and their imaging appearances in conventional and advanced imaging studies, including optimal technical considerations for each technique. Advanced magnetic resonance imaging (MRI) techniques are highlighted, illustrating their complementary role to conventional MRI, in particular their potential impact in avoiding additional studies.

Beyond the abdominal and pelvic cavity: abdominal wall and spinal "Aunt Minnies"

Abdominal wall and spinal soft tissue findings are frequently encountered on CT or MR imaging of the abdomen and pelvis. Many of these entities have specific imaging findings, for which a definitive diagnosis can be made without the need for further work up. These abdominal wall and spinal findings may be diagnostically challenging for sub-specialized abdominal radiologists who are unfamiliar with their appearance and appropriate management. This review article describes and illustrates pathognomonic or characteristic abdominal wall and spinal pathologies, which reside outside the abdominopelvic cavity. The cases selected all have findings that allow a confident diagnosis without further imaging or intervention. The cases presented include myonecrosis, intramuscular abscess, myositis, iliopsoas bursitis, Morel-Lavallée lesion, hydrocele of canal of Nuck, Klippel Trenaunay Weber syndrome, neurofibroma with target sign, perineural cysts, filum terminale lipoma, calvarial bone flap, transverse rectus abdominis muscle (TRAM) flap, liposuction, and hidradenitis suppurativa, among others. Although not all-encompassing, this paper will help abdominal radiologists to accurately diagnose a variety of abdominal and pelvic extra-cavitary soft tissue pathologies by identifying key radiologic findings.

Bone Marrow Changes and Lesions of Diabetic Foot and Ankle Disease: Conventional and Advanced Magnetic Resonance Imaging

Diabetic foot and ankle complications contribute to substantial mortality and morbidity. Early detection and treatment can lead to better patient outcomes. The primary diagnostic challenge for radiologists is distinguishing Charcot's neuroarthropathy from osteomyelitis. Magnetic resonance imaging (MRI) is the preferred imaging modality for assessing diabetic bone marrow alterations and for identifying diabetic foot complications. Several recent technical advances in MRI, such as the Dixon technique, diffusion-weighted imaging, and dynamic contrast-enhanced imaging, have led to improved image quality and increased capability to add more functional and quantitative information.We discuss the bone marrow abnormalities encountered in daily radiologic assessment: osteopenia, reactive bone marrow edema-like signal, insufficiency fractures, Charcot's neuroarthropathy, osteomyelitis, serous marrow atrophy, digital ischemia, and bone infarcts, along with their pathophysiology and the conventional and advanced imaging techniques used for a comprehensive marrow evaluation.

Hybrid imaging of Diabetic Foot Infections

Diabetic foot infections, a common but diagnostically challenging clinical presentation, requires the difficult differentiation between soft tissue-only infection, diabetic neuropathic osteoarthropathy, osteomyelitis or a combination of these pathological processes. While there are clinical predictors for osteomyelitis and simple bedside tests available, imaging is often required for accurate diagnosis. A variety of anatomic and molecular imaging tests are in clinical use, each with its advantages and disadvantages. This review will provide an overview of the different available imaging modalities and their diagnostic criteria, emphasizing the role of hybrid imaging for the accurate diagnosis of osteomyelitis.

Non-Vascular Considerations When Interpreting Extremity Arterial and Venous Examinations

Peripheral arterial and venous examinations are performed regularly in vascular labs and interpreted by physicians of different specialities. Many vascular examinations have nonvascular pathology that is either inadvertently imaged by the sonographer or imaged with intent as it relates to patient's symptoms. It is prudent for every reader of vascular studies to be acquainted with the sonographic appearance of these non-vascular lesions to enable appropriate and optimal interpretation that has a direct bearing on patient's clinical care. Our review includes a discussion of the nonvascular pathologies like lymph nodes, soft tissue edema, soft tissue fluid collections, musculotendinous injuries, soft tissue masses, and joint and bursal pathologies that may be encountered during interpretation of vascular exams. The pictorial essay includes a discussion of their sonographic appearances and pitfalls in interpretation. Multiple illustrative examples and sonographic images of the non-vascular pathologies found during interpretation of vascular studies have been utilized to highlight their appearances.

The sonographic quantitative assessment of the deltoid muscle to detect type 2 diabetes mellitus: a potential noninvasive and sensitive screening method?

BACKGROUND

In our previous published study, we demonstrated that a qualitatively assessed elevation in deltoid muscle echogenicity on ultrasound was both sensitive for and a strong predictor of a type 2 diabetes (T2DM) diagnosis. This study aims to evaluate if a sonographic quantitative assessment of the deltoid muscle can be used to detect T2DM.

METHODS

Deltoid muscle ultrasound images from 124 patients were stored: 31 obese T2DM, 31 non-obese T2DM, 31 obese non-T2DM and 31 non-obese non-T2DM. Images were independently reviewed by 3 musculoskeletal radiologists, blinded to the patient's category. Each measured the grayscale pixel intensity of the deltoid muscle and humeral cortex to calculate a muscle/bone ratio for each patient. Following a 3-week delay, the 3 radiologists independently repeated measurements on a randomly selected 40 subjects. Ratios, age, gender, race, body mass index, insulin usage and hemoglobin A_1c were analyzed. The difference among the 4 groups was compared using analysis of variance or chi-square tests. Both univariate and multivariate linear mixed models were performed. Multivariate mixed-effects regression models were used, adjusting for demographic and clinical variables. Post hoc comparisons were done with Bonferroni adjustments to identify any differences between groups. The sample size achieved 90% power. Sensitivity and specificity were calculated based on set threshold ratios. Both intra- and inter-radiologist variability or agreement were assessed.

RESULTS

A statistically significant difference in muscle/bone ratios between the groups was identified with the average ratios as follows: obese T2DM, 0.54 (P < 0.001); non-obese T2DM, 0.48 (P < 0.001); obese non-T2DM, 0.42 (P = 0.03); and non-obese non-T2DM, 0.35. There was excellent inter-observer agreement (intraclass correlation coefficient 0.87) and excellent intra-observer agreements (intraclass correlation coefficient 0.92, 0.95 and 0.94). Using threshold ratios, the sensitivity for detecting T2DM was 80% (95% CI 67% to 88%) with a specificity of 63% (95% CI 50% to 75%).

CONCLUSIONS

The sonographic quantitative assessment of the deltoid muscle by ultrasound is sensitive and accurate for the detection of T2DM. Following further studies, this process could translate into a dedicated, simple and noninvasive screening method to detect T2DM with the prospects of identifying even a fraction of the undiagnosed persons worldwide. This could prove especially beneficial in screening of underserved and underrepresented communities.

Diabetes mellitus tendino-myopathy: epidemiology, clinical features, diagnosis and management of an overlooked diabetic complication

Tendino-myopathy, an unexplored niche, is a non-vascular unstated T2DM complication, which is largely disregarded in clinical practice, thus, we aim to explore it in this review. Literature search using published data from different online resources. Epidemiologically, reported prevalence varies around 10-90%, which is marked variable and unreliable. Clinically, diabetic tendino-myopathy is typified by restriction of movement, pain/tenderness, cramps and decreased functions. Moreover, myopathy is characterized by muscle atrophy, weakness and ischemia, and tendinopathy by deformities and reduced functions/precision. In tendonapthy, the three most affected regions are: the hand (cheiroarthropathy, Dupuytren's contracture, flexor tenosynovitis and carpel tunnel syndrome), shoulder (adhesive capsulitis, rotator cuff tendinopathy and tenosynovitis) and foot (Achilles tendinopathy with the risk of tear/rupture), in addition to diffuse idiopathic skeletal hyperostosis. Pathologically, it is characterized by decreased muscle fiber mass and increased fibrosis, with marked extracellular matrix remodeling and deposition of collagens. The tendon changes include decreased collagen fibril diameter, changed morphology, increased packing and disorganization, with overall thickening, and calcification. Diagnosis is basically clinical and radiological, while diagnostic biomarkers are awaited. Management is done by diabetes control, special nutrition and physiotherapy, while analgesics, steroids and surgery are used in tendinopathy. Several antisarcopenic drugs are in the pipeline. This review aims to bridge clinical practice with research and update routine diabetic checkup by inclusion of tendino-myopathies in the list with an emphasis on management.

Diabetic foot infections: how to investigate more efficiently? A retrospective study in a quaternary university center

Background

Diabetic foot infections are frequent and associated with substantial morbidity and substantial cost to the healthcare system. Up to 34% of diabetic patients will develop an ulcer potentially leading to osteomyelitis. Imaging plays a crucial role in the diagnostic process. Imaging modalities to investigate the diabetic foot infection are many and imaging prescription habits remain heterogeneous across physicians. We aimed to improve the appropriateness of imaging examination requested, and performed, for diabetic foot osteomyelitis and we aimed to reduce the overall imaging-related cost.

Methods

Local committee was created to develop an algorithm for suspected diabetic foot osteomyelitis. Best practices were defined by the local algorithm. The algorithm was shared with our physicians. Pre- and post-intervention analysis was conducted retrospectively. All adult diabetic patients with suspected foot osteomyelitis were included. Adherence to best practices was measured. Statistical analysis with Chi-Square and two tailed unpaired t-test was performed.

Results

Pre-intervention cohort had 223 patients (mean age: 63; 168 men). Adherence to best practice was 43%. Scintigraphy (48%) preferred over MRI (44%) and performed simultaneously in 15 patients. Post-intervention cohort had 73 patients (mean age: 66; 62 men). Adherence to best practice was 78%, improved by 35% (p < 0.001). MRI (51%) preferred over scintigraphy (23%) and performed simultaneously in three patients. Scintigraphy examinations decreased by 25% (p < 0.001). MRI examinations increased by 7% (p = 0.32). Hospital imaging related fees decreased by 22% per patient (p = 0.002).

Conclusion

Interval improvement in adequate adherence while reducing unnecessary examinations for patients and decreasing costs for the healthcare system was observed.

Diabetic myonecrosis, an uncommon presentation of diabetes mellitus in tropical area: A case report

Diabetic myonecrosis is an uncommon complication related to long‐standing poorly controlled diabetes. A 33‐year‐old Sudanese male patient with type one diabetes presented with progressive, severe bilateral thigh pain with low‐grade fever. Laboratory results show hyperglycemia with ketonuria and elevated creatine kinase but normal white cell blood count. The patient was diagnosed initially with diabetic ketoacidosis with pyomyositis and received analgesic and insulin; the patient partially improved. After the second evaluation, bilateral thigh MRI was requested and shows diffuse edema involving the medial muscle group of the upper third of the right side with intramuscular facial edema, appearing as low signal in T1 and high signal in T2 and fat suppression images with no evidence of collection or abscess. Diagnosis of diabetic myonecrosis was made. The patient was managed conservatively and discharge on aspirin with full recovery.

Bone and Joint Infections: The Role of Imaging in Tailoring Diagnosis to Improve Patients' Care

Imaging is needed for the diagnosis of bone and joint infections, determining the severity and extent of disease, planning biopsy, and monitoring the response to treatment. Some radiological features are pathognomonic of bone and joint infections for each modality used. However, imaging diagnosis of these infections is challenging because of several overlaps with non-infectious etiologies. Interventional radiology is generally needed to verify the diagnosis and to identify the microorganism involved in the infectious process through imaging-guided biopsy. This narrative review aims to summarize the radiological features of the commonest orthopedic infections, the indications and the limits of different modalities in the diagnostic strategy as well as to outline recent findings that may facilitate diagnosis.

Irregularity in Plantar Fascia, Muscle Edema and Tendon Thickness in Patients with High-Risk for Diabetic Foot

AIM

To investigate the alterations in the plantar fascia (PF), intrinsic muscles, and tendons in the feet of patients at high risk for developing diabetic foot.

METHODS

The healthy feet of 22 patients with type 2 diabetes, who had developed diabetic foot ulcers on a single foot without any pathology on the contralateral extremity, and those of 22 healthy volunteers were evaluated by magnetic resonance imaging. The volume of the Achilles tendon (AT), the surface area of the PF, the thickness of AT, flexor hallucis longus, flexor digitorum longus, tibialis posterior, and peroneus longus tendons, irregularity in the PF, and edema of intrinsic foot muscles were examined.

RESULTS

Nineteen patients (86%) had irregularity in the PF, whereas none of the healthy controls had any (p<0.001). Intrinsic muscle edema was more common in the group with diabetes (p=0.006). The volume of AT and the surface area of PF were decreased in patients with peripheral arterial disease (PAD) (p<0.05). Patients with diabetes mellitus but without PAD had a larger surface area of PF than that of controls (p<0.05). There were no differences in the volume of AT, the surface area of the PF, and other tendon thickness between the groups.

CONCLUSION

Irregularity in the PF and muscle edema may indicate a high risk for the diabetic foot. The presence of PAD may lead to regression in the structure of AT and PF.

Complications in the spine associated with type 2 diabetes: The role of advanced glycation end-products

Type 2 diabetes mellitus (T2D) is an increasingly prevalent disease with numerous comorbidities including many in the spine. T2D is strongly linked with vertebral fractures, intervertebral disc (IVD) degeneration, and severe chronic spinal pain. Yet the causative mechanism for these musculoskeletal impairments remains unclear. The chronic hyperglycemic state in T2D promotes the formation of advanced glycation end-products (AGEs) in tissues, and the accumulation of AGEs may play a role in musculoskeletal complications by modifying the extracellular matrix, impairing cellular homeostasis, and perpetuating an inflammatory cascade via its receptor (RAGE). The AGE and RAGE associated alterations in extracellular matrix composition and morphological features of the vertebral bodies and IVDs are likely contributors to the incidence and severity of spinal pathologies in T2D. This review will broadly examine the effects of AGEs on tissues in the spine in the context of T2D, with an emphasis on the changes in the vertebrae and the IVD. Along with the clinical and epidemiological findings, we will provide an overview of preclinical rodent models of T2D that exhibit deficits in the IVD and vertebral bone. Elucidating the role of AGEs and RAGE will be crucial for understanding the disease mechanisms and translation therapies of musculoskeletal pathologies in T2D.

Diabetic myonecrosis in end-stage renal disease

Diabetic myonecrosis or muscle infarction (DMI), a clinicoradiological entity is an underdiagnosed complication of diabetes mellitus. It refers to spontaneous aseptic necrosis of skeletal muscles commonly of the lower limb without evidence of any large vessel disease. It presents as painful swollen limb without any external insult in patients with long-standing diabetes mellitus with other microvascular complications especially nephropathy. We present four instances of DMI in our patients who had end-stage renal disease with a varied course.

Magnetic Resonance Imaging of Diabetic Foot Osteomyelitis: Imaging Accuracy in Biopsy-Proven Disease

Magnetic resonance imaging (MRI) is the recommended diagnostic imaging technique for diabetic foot osteomyelitis (DFO). The gold standard to diagnose osteomyelitis is bone biopsy with a positive culture and/or histopathology finding consistent with osteomyelitis. The purpose of this study is to assess the accuracy of MRI readings in biopsy-proven diabetic foot osteomyelitis with a second read done by a blinded, expert musculoskeletal radiologist. A retrospective chart review of 166 patients who received a bone biopsy to confirm the diagnosis of a suspected DFO at a large county hospital between 2010 and 2014. A second, blinded musculoskeletal radiologist reviewed the images for accuracy, once the official reading was recorded. Imaging results were correlated with the final diagnosis of osteomyelitis determined by bone biopsy. In 17 of 58 patients (29.3%), the diagnosis of DFO by MRI was not confirmed by bone biopsy. There were 12 false positives and 5 false negatives. After the second expert read, there were 5 false positives and 4 false negatives. The overall accuracy was 84% for the second read. Our study demonstrated results comparable to the previously reported meta-analysis findings. There is a clear variation on the read of MRI that could lead to an incorrect diagnosis of DFO. An integrated approach with evaluation of clinical findings, communication with radiologist about the MRI results when indicated, and bone biopsy is warranted for accurate diagnosis management of DFO.

Müller-Weiss disease: Four case reports

BACKGROUND

Müller-Weiss disease (MWD) is an idiopathic foot condition characterized by spontaneous tarsal “scaphoiditis” in adults. Frequently bilateral and affecting females during the 4^th-6^th decades of life, the pathogenesis of MWD remains unclear: It has been traditionally considered a spontaneous osteonecrosis of the navicular. The typical presentation of MWD is a long period of subtle discomfort followed by prolonged standing, atraumatic, disabling pain. Currently, there is no gold standard for the treatment of patients with MWD. Most support initial conservative therapy. Operative treatment should be considered for failure of conservative therapies longer than 6 months. The indication for surgery is severity of symptoms rather than severity of deformities. Operative treatment options include core decompression, internal fixation of the tarsal navicular, open or arthroscopic triple fusion, talo-navicular or talo-navicular-cuneiform arthrodesis, and navicular excision with reconstruction of the medial column.

CASE SUMMARY

In this study, we report four patients affected by MWD. Clinical and radiographic assessment, follow-up and treatment are reported.

CONCLUSION

As it is frequently misdiagnosed, MWD is challenging for orthopedic surgeons. Early diagnosis and effective treatment are mandatory to avoid sequelae.

Arabinofuranose-derived positron-emission tomography radiotracers for detection of pathogenic microorganisms

PURPOSE

Detection of bacteria-specific metabolism via positron emission tomography (PET) is an emerging strategy to image human pathogens, with dramatic implications for clinical practice. In silico and in vitro screening tools have recently been applied to this problem, with several monosaccharides including l-arabinose showing rapid accumulation in Escherichia coli and other organisms. Our goal for this study was to evaluate several synthetically viable arabinofuranose-derived 18 F analogs for their incorporation into pathogenic bacteria.

PROCEDURES

We synthesized four radiolabeled arabinofuranose-derived sugars: 2-deoxy-2-[18 F]fluoro-arabinofuranoses (d-2-18 F-AF and l-2-18 F-AF) and 5-deoxy-5-[18 F]fluoro-arabinofuranoses (d-5-18 F-AF and l-5-18 F-AF). The arabinofuranoses were synthesized from 18 F- via triflated, peracetylated precursors analogous to the most common radiosynthesis of 2-deoxy-2-[18 F]fluoro-d-glucose ([18 F]FDG). These radiotracers were screened for their uptake into E. coli and Staphylococcus aureus. Subsequently, the sensitivity of d-2-18 F-AF and l-2-18 F-AF to key human pathogens was investigated in vitro.

RESULTS

All 18 F radiotracer targets were synthesized in high radiochemical purity. In the screening study, d-2-18 F-AF and l-2-18 F-AF showed greater accumulation in E. coli than in S. aureus. When evaluated in a panel of pathologic microorganisms, both d-2-18 F-AF and l-2-18 F-AF demonstrated sensitivity to most gram-positive and gram-negative bacteria.

CONCLUSIONS

Arabinofuranose-derived 18 F PET radiotracers can be synthesized with high radiochemical purity. Our study showed absence of bacterial accumulation for 5-substitued analogs, a finding that may have mechanistic implications for related tracers. Both d-2-18 F-AF and l-2-18 F-AF showed sensitivity to most gram-negative and gram-positive organisms. Future in vivo studies will evaluate the diagnostic accuracy of these radiotracers in animal models of infection.

Guidelines on the diagnosis and treatment of foot infection in persons with diabetes (IWGDF 2019 update)

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the diagnosis and treatment of foot infection in persons with diabetes and updates the 2015 IWGDF infection guideline. On the basis of patient, intervention, comparison, outcomes (PICOs) developed by the infection committee, in conjunction with internal and external reviewers and consultants, and on systematic reviews the committee conducted on the diagnosis of infection (new) and treatment of infection (updated from 2015), we offer 27 recommendations. These cover various aspects of diagnosing soft tissue and bone infection, including the classification scheme for diagnosing infection and its severity. Of note, we have updated this scheme for the first time since we developed it 15 years ago. We also review the microbiology of diabetic foot infections, including how to collect samples and to process them to identify causative pathogens. Finally, we discuss the approach to treating diabetic foot infections, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and for bone infections, when and how to approach surgical treatment, and which adjunctive treatments we think are or are not useful for the infectious aspects of diabetic foot problems. For this version of the guideline, we also updated four tables and one figure from the 2016 guideline. We think that following the principles of diagnosing and treating diabetic foot infections outlined in this guideline can help clinicians to provide better care for these patients.

The Hyperechoic Appearance of the Deltoid Muscle on Shoulder Ultrasound Imaging as a Predictor of Diabetes and Prediabetes

OBJECTIVES

To evaluate whether the ultrasound appearance of the deltoid muscle in diabetic patients differs from that in obese nondiabetic patients.

METHODS

Ultrasound images of the deltoid muscle from 137 type 2 diabetic patients (including 13 prediabetic patients) and 49 obese nondiabetic patients were blindly reviewed by 2 musculoskeletal radiologists, and by a third when arbitration was needed, to determine whether the appearance was "normal," "suspected diabetes," or "definite diabetes." Age, sex, race, body mass index (BMI), insulin use, and hemoglobin A_1c were analyzed. This retrospective study included patients presenting between October 2005 and November 2017. Statistical analyses included a 2-sided sample t test or Wilcoxon rank sum test and a χ² or Fisher exact test. Statistical significance was defined as P < .05.

RESULTS

The type 2 diabetic patients included 98 women and 39 men aged 29 to 92 years, and the nondiabetic patients included 19 women and 30 men aged 18 to 75 years. A consensus diagnosis of definite diabetes by the musculoskeletal radiologists based on a hyperechoic deltoid was a powerful predictor of diabetes, with a positive predictive value of 89%. A hyperechoic deltoid was also a powerful predictor of prediabetes. Of the 13 prediabetic patients, all had the same hyperechoic appearance of the diabetic deltoid, regardless of BMI. Although obese diabetic patients more often had a diagnosis of definite diabetes, the BMI alone could not explain the increased echogenicity, as obese nondiabetic patients' deltoid muscles did not appear as hyperechoic and were correctly categorized as not having definite diabetes with 82% specificity.

CONCLUSIONS

The characteristic hyperechoic deltoid appearance is a strong predictor of both diabetes and prediabetes and differs from that of obese nondiabetic patients.

High Enantiomeric Excess In-Loop Synthesis of d-[methyl-11C]Methionine for Use as a Diagnostic Positron Emission Tomography Radiotracer in Bacterial Infection

Currently, there exists no accurate, noninvasive clinical imaging method to detect living bacteria in vivo. Our goal is to provide a positron emission tomography (PET) method to image infection by targeting bacteria-specific metabolism. Standard of care methodologies detect morphologic changes, image immunologic response to infection, or employ invasive tissue sampling with associated patient morbidity. These strategies, however, are not specific for living bacteria and are often inadequate to detect bacterial infection during fever workup. As such, there is an unmet clinical need to identify and validate new imaging tools suitable for noninvasive, in vivo (PET) imaging of living bacteria. We have shown that d-[methyl-¹¹C]methionine (d-[¹¹C]Met) can distinguish active bacterial infection from sterile inflammation in a murine infection model and is sensitive to both Gram-positive and Gram-negative bacteria. Here, we report an automated and >99% enantiomeric excess (ee) synthesis of d-[¹¹C]Met from a linear d-homocysteine precursor, a significant improvement over the previously reported synthesis utilizing a d-homocysteine thiolactone hydrochloride precursor with approximately 75-85% ee. Furthermore, we took additional steps toward applying d-[¹¹C]Met to infected patients. d-[¹¹C]Met was subject to a panel of clinically relevant bacterial strains and demonstrated promising sensitivity to these pathogens. Finally, we performed radiation dosimetry in a normal murine cohort to set the stage for translation to humans in the near future.

Diabetic myonecrosis: A case series of two dialysis-dependent patients

Diabetic myonecrosis (DMN) is a rare microangiopathic disorder that can present as an acutely painful and swollen limb in patients with established diabetes mellitus. The condition can be diagnosed noninvasively with magnetic resonance imaging and resolves with analgesia, bed rest, and glycemic control. Due to a relative lack of awareness regarding the condition, avoidable interventions such as muscle biopsies and even surgery are sometimes pursued, which have been associated with prolonged recovery times. The majority of patients with DMN have diabetic nephropathy, yet this condition is not widely recognized in the nephrology community, resulting in delayed diagnosis and patients undergoing unnecessary and potentially harmful investigations. There is therefore a need for increased awareness of the condition among renal physicians. Here, we report the cases of two patients on hemodialysis who were ultimately diagnosed with DMN, along with a review of the literature.

Radiographic Presentation of Delayed Diagnosis of Charcot Foot in a 56-Year-Old Patient With No Reported History of Diabetes: A Case Report

Objective

The purpose of this case report is to describe the radiographic presentation of a patient with neuropathic osteoarthropathy.

Clinical Features

A 56-year-old white man presented to the diagnostic imaging department of a chiropractic teaching institution for the radiographic examination of the left foot. He had a 6-month history of left foot pain unresponsive to chiropractic care. The patient had reported no history of diabetes and denied any trauma, surgery, or malignancy.

Intervention and Outcome

Based upon the history, a 3-view radiographic examination of the left foot using computed radiography was performed. Radiographic abnormalities included osseous resorption, architectural foot disorganization, and dissociation and collapse of the anatomical alignment between the intertarsal and tarsal-metatarsal articulations. Intra-articular osseous debris formation with periarticular edema of the midfoot was noted. After the radiological diagnosis, the patient was subsequently investigated and diagnosed with type 2 diabetes mellitus. Thus, there were radiographic findings of poorly controlled or untreated diabetes mellitus with the resultant complication of neuropathic osteoarthropathy.

Conclusion

Some patients with type 2 diabetes may present with covert manifestations and other symptoms, such as a history of unexplained foot pain. The patient in this case with diabetes-induced neuropathic osteoarthropathy demonstrates that these findings should raise suspicion and result in an appropriate follow-up investigation.

Detection of Bacteria-Specific Metabolism Using Hyperpolarized [2-13C]Pyruvate

The differentiation of bacterial infection from other causes of inflammation is difficult in clinical practice and is critical where patient outcomes rely heavily on early interventions. In addition to physical exam and laboratory markers, several imaging modalities are frequently employed, but these techniques generally target the host immune response, rather than the living microorganisms themselves. Here, we describe a method to detect bacteria-specific metabolism using hyperpolarized (HP) ¹³C magnetic resonance spectroscopy. This technology allows visualization of the real-time conversion of enriched ¹³C substrates to their metabolic products, identified by their distinct chemical shifts. We have identified the rapid metabolism of HP [2-¹³C]pyruvate to [1-¹³C]acetate as a metabolic signature of common bacterial pathogens. We demonstrate this conversion in representative Gram-negative and Gram-positive bacteria, namely, Escherichia coli and Staphylococcus aureus, and its absence in key mammalian cell types. Furthermore, this conversion was successfully modulated in three mutant strains, corresponding to deletions of relevant enzymes.

Beyond ulcers and osteomyelitis: imaging of less common musculoskeletal complications in diabetes mellitus

Metabolic perturbations in diabetes mellitus affect various organ systems and can lead to end-organ failure. Though most musculoskeletal (MSK) complications of diabetes mellitus are usually not life-threatening, they are often the cause of significant morbidity. While some of the MSK complications have a proven association with diabetes mellitus, others have been loosely associated because of their frequent coexistence, as are the rheumatologic complications. While many of these conditions are well-known, some are overlooked in routine clinical practice. This article focuses on highlighting key imaging features of less common MSK complications and associations of diabetes mellitus.

Imaging Active Infection in vivo Using D-Amino Acid Derived PET Radiotracers

Occult bacterial infections represent a worldwide health problem. Differentiating active bacterial infection from sterile inflammation can be difficult using current imaging tools. Present clinically viable methodologies either detect morphologic changes (CT/ MR), recruitment of immune cells (¹¹¹In-WBC SPECT), or enhanced glycolytic flux seen in inflammatory cells (¹⁸F-FDG PET). However, these strategies are often inadequate to detect bacterial infection and are not specific for living bacteria. Recent approaches have taken advantage of key metabolic differences between prokaryotic and eukaryotic organisms, allowing easier distinction between bacteria and their host. In this report, we exploited one key difference, bacterial cell wall biosynthesis, to detect living bacteria using a positron-labeled D-amino acid. After screening several ¹⁴C D-amino acids for their incorporation into E. coli in culture, we identified D-methionine as a probe with outstanding radiopharmaceutical potential. Based on an analogous procedure to that used for L-[methyl-¹¹C]methionine ([¹¹C] L-Met), we developed an enhanced asymmetric synthesis of D-[methyl-¹¹C]methionine ([¹¹C] D-Met), and showed that it can rapidly and selectively differentiate both E. coli and S. aureus infections from sterile inflammation in vivo. We believe that the ease of [¹¹C] D-Met radiosynthesis, coupled with its rapid and specific in vivo bacterial accumulation, make it an attractive radiotracer for infection imaging in clinical practice.

Diagnostic performance of diffusion-weighted MR imaging in differentiation of diabetic osteoarthropathy and osteomyelitis in diabetic foot

PURPOSE

To study the diagnostic performance of diffusion weighted MR imaging in differentiation of diabetic osteoarthropathy and osteomyelitis in diabetic foot.

PATIENTS AND METHODS

This prospective study was carried out on 41 patients with diabetic foot, 22 males and 19 females with mean age of 51 years. They underwent diffusion-weighted MR imaging of the foot. The apparent diffusion coefficient (ADC) values of the bony lesions were calculated by two reviewers and correlated with the surgical findings or biopsy. The kappa statistic (k) was used to estimate the proportion of inter-observer agreement of two reviewers.

RESULTS

The mean ADC of acute diabetic osteoarthropathy was 1.27±0.19×10^-3mm²/s for reviewer 1 and 1.26±0.21×10^-3mm²/s for reviewer 2. The mean ADC value in diabetic osteomyelitis was 0.86±0.11×10^-3mm²/s for reviewer 1 and 0.85±0.12×10^-3mm²/s for reviewer 2. There was excellent inter-observer agreement of ADC value of bony lesions in diabetic foot by both reviewers (K=0.93). There was statistically significant difference in the ADC values of both groups (P=0.001). The cut-off point of ADC value of both reviewers used in differentiating acute diabetic osteoarthropathy and osteomyelitis were 0.98×10^-3mm²/s and 1.04×10^-3mm²/s with an accuracy of 94% and 93% and area under the curve of 0.94 and 0.93 respectively.

CONCLUSION

We conclude that the ADC value is a non-invasive imaging parameter that can help in differentiation of diabetic osteoarthropathy from osteomyelitis with excellent inter-observer agreement.

Dermatological and musculoskeletal assessment of diabetic foot: A narrative review

AIMS

Diabetic Foot Syndrome (DFS) is the most costly and devastating complication of diabetes mellitus (DM), which early effective assessment can reduce the severity of complications including ulceration and amputations. This study aimed to review dermatological and musculoskeletal assessment of diabetic foot.

MATERIALS AND METHODS

In this review article, we searched for articles published between March 1, 1980 and July 28, 2015 in PubMed, Science Direct, Embase, Web of Science, and Scopus, for both English and non-English language articles with the following keywords: "Diabetic foot syndrome", "Ulceration", "Amputation", "Foot assessment", "Skin disorders" and "Musculoskeletal deformities".

RESULTS

In dermatological dimension, most studies focused on elucidated changes in skin temperature, color, hardiness and turgor as well as common skin disorders such as Diabetic Dermopathy (DD), Necrobiosis Lipoidica Diabeticorum (NLD) and Diabetic Bullae (DB), which are common in diabetic patients and have high potential for leading to limb-threatening problems such as ulceration and infection. In musculoskeletal dimension, most studies focused on range of motion and muscle strength, gait patterns and as well as foot deformities especially Charcot osteoarthropathy (COA), which is the most destructive musculoskeletal complication of diabetes.

CONCLUSION

DFS as a common condition in DM patients lead to ulceration and lower limb amputation frequently unless a prompt and comprehensive assessment was taken. So that dermatological and musculoskeletal assessments are usually neglected in primary health care, these assessments should be done frequently to reduce the high risk of serious complications.

Sonographic Findings of Common Musculoskeletal Diseases in Patients with Diabetes Mellitus

Diabetes mellitus (DM) can accompany many musculoskeletal (MSK) diseases. It is difficult to distinguish the DM-related MSK diseases based on clinical symptoms alone. Sonography is frequently used as a first imaging study for these MSK symptoms and is helpful to differentiate the various DM-related MSK diseases. This pictorial essay focuses on sonographic findings of various MSK diseases that can occur in diabetic patients.

Effect of supervised exercise training on musculoskeletal symptoms and function in patients with type 2 diabetes: the Italian Diabetes Exercise Study (IDES)

Musculoskeletal disorders are common in subjects with type 2 diabetes mellitus (T2DM) and may represent a barrier to physical activity (PA). In the Italian Diabetes and Exercise Study, we assessed whether a strategy aimed at minimizing the risk of injury and worsening of musculoskeletal symptoms favors participation in exercise training and results in improvements in joint-specific functional scores, along with amelioration of metabolic profile. Sedentary patients with T2DM (n = 606) from 22 outpatient diabetes clinics were randomized to twice-a-week supervised aerobic and resistance training plus exercise counseling (EXE) versus counseling alone (CON) for 12 months. Musculoskeletal symptoms were evaluated at baseline in the entire cohort by the use of a self-reported questionnaire in order to design tailored exercise programs with exclusion of painful segments, and validated joint-specific scores were calculated at the end of study in a subgroup of CON (n = 65) and EXE subjects (n = 62). Musculoskeletal symptoms were present in more than ¾ of EXE and CON subjects. Yet, volumes of non-supervised PA were high, whereas dropout rates and adverse events were low in both groups. Moreover, in the EXE group, no difference was observed between patients with and without symptoms in session attendance and PA/exercise volume. Scores for symptoms and functional status of limbs and spine were significantly better in EXE than in CON subjects and correlated with PA/exercise volume and improvements in fitness parameters. Preliminary evaluation of musculoskeletal symptoms is useful in favoring compliance with supervised training programs and obtaining significant benefits to the functional status of the involved joints.

Musculoskeletal manifestations of endocrine disorders

Endocrine disorders can lead to disturbances in numerous systems within the body, including the musculoskeletal system. Radiological evaluation of these conditions can demonstrate typical appearances of the bones and soft tissues. Knowledge of these patterns can allow the radiologist to suggest a diagnosis that may not be clinically apparent. This review will highlight the typical musculoskeletal findings of acromegaly, hypercortisolism, hyperthyroidism, hypothyroidism, hyperparathyroidism, pseudo- and pseudopseudohypoparathyroidism, and diabetes mellitus. The radiological manifestations of each of these endocrine disorders, along with a brief discussion of the pathophysiology and clinical implications, will be discussed.

Imaging of diabetic foot infections

Complications from diabetic foot infections are a leading cause of nontraumatic lower-extremity amputations. Nearly 85% of these amputations result from an infected foot ulcer. Osteomyelitis is present in approximately 20% of diabetic foot infections. It is imperative that clinicians make quick and successful diagnoses of diabetic foot osteomyelitis (DFO) because a delay in treatment may lead to worsening outcomes. Imaging studies, such as plain films, bone scans, musculoskeletal ultrasound, computerized tomography scans, magnetic resonance imaging, and positron emission tomography scans, aid in the diagnosis. However, there are several mimickers of DFO, which present problems to making a correct diagnosis.