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Systematic review: investigating the added diagnostic value of gadolinium contrast agents for osteomyelitis in the appendicular skeleton. Skeletal Radiol 2022; 51:1285-1296. [PMID: 34643771 DOI: 10.1007/s00256-021-03915-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 09/13/2021] [Accepted: 09/17/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Osteomyelitis is an infection of the bone marrow. MRI with gadolinium-based contrast is frequently performed for cases of suspected osteomyelitis. The objective of this systematic review is to examine the diagnostic accuracy of contrast-enhanced vs non-contrast-enhanced MRI for osteomyelitis in the appendicular skeleton. MATERIALS AND METHODS We conducted a systematic review of MRI in the diagnosis of osteomyelitis by searching MEDLINE and EMBASE from January 2000 to March 2020. There were 21 studies that met the inclusion criteria for the systematic review for a total of 1095 patients. Analytic methods were based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Evidence was evaluated using the STARD criteria for evaluation of completeness and transparency of reporting. RESULTS For diagnosing osteomyelitis in the appendicular skeleton, MRI with gadolinium-based contrast has 89% sensitivity (95% CI, 86-92%), 79% specificity (95% CI, 75-83%), and 90% overall diagnostic accuracy ([SE] = 0.03). For diagnosing osteomyelitis in the appendicular skeleton, MRI without gadolinium-based contrast has a 92% sensitivity (95% CI, 87-96%), 89% specificity (95% CI, 84-93%), and 96% overall diagnostic accuracy ([SE] = 0.03). The median score of included studies was 85% utilizing the STARD criteria with excellent interobserver agreement of 83.4%. Limitations included small sample size of studies, with retrospective designs. CONCLUSION No evidence was found to suggest an added diagnostic value of gadolinium contrast for the diagnosis of osteomyelitis in the appendicular skeleton. For routine cases of suspected non-spinal osteomyelitis, non-contrast MRI of the area of interest is the next most appropriate study after radiographs.
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Rubitschung K, Sherwood A, Crisologo AP, Bhavan K, Haley RW, Wukich DK, Castellino L, Hwang H, La Fontaine J, Chhabra A, Lavery L, Öz OK. Pathophysiology and Molecular Imaging of Diabetic Foot Infections. Int J Mol Sci 2021; 22:11552. [PMID: 34768982 PMCID: PMC8584017 DOI: 10.3390/ijms222111552] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 10/16/2021] [Accepted: 10/20/2021] [Indexed: 12/27/2022] Open
Abstract
Diabetic foot infection is the leading cause of non-traumatic lower limb amputations worldwide. In addition, diabetes mellitus and sequela of the disease are increasing in prevalence. In 2017, 9.4% of Americans were diagnosed with diabetes mellitus (DM). The growing pervasiveness and financial implications of diabetic foot infection (DFI) indicate an acute need for improved clinical assessment and treatment. Complex pathophysiology and suboptimal specificity of current non-invasive imaging modalities have made diagnosis and treatment response challenging. Current anatomical and molecular clinical imaging strategies have mainly targeted the host's immune responses rather than the unique metabolism of the invading microorganism. Advances in imaging have the potential to reduce the impact of these problems and improve the assessment of DFI, particularly in distinguishing infection of soft tissue alone from osteomyelitis (OM). This review presents a summary of the known pathophysiology of DFI, the molecular basis of current and emerging diagnostic imaging techniques, and the mechanistic links of these imaging techniques to the pathophysiology of diabetic foot infections.
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Affiliation(s)
- Katie Rubitschung
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.R.); (A.S.); (A.C.)
| | - Amber Sherwood
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.R.); (A.S.); (A.C.)
| | - Andrew P. Crisologo
- Department of Plastic Surgery, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA;
| | - Kavita Bhavan
- Department of Internal Medicine, Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.B.); (L.C.)
| | - Robert W. Haley
- Department of Internal Medicine, Epidemiology Division, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA;
| | - Dane K. Wukich
- Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA;
| | - Laila Castellino
- Department of Internal Medicine, Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.B.); (L.C.)
| | - Helena Hwang
- Department of Pathology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA;
| | - Javier La Fontaine
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (J.L.F.); (L.L.)
| | - Avneesh Chhabra
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.R.); (A.S.); (A.C.)
| | - Lawrence Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (J.L.F.); (L.L.)
| | - Orhan K. Öz
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.R.); (A.S.); (A.C.)
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Rubitschung K, Sherwood A, Crisologo AP, Bhavan K, Haley RW, Wukich DK, Castellino L, Hwang H, La Fontaine J, Chhabra A, Lavery L, Öz OK. Pathophysiology and Molecular Imaging of Diabetic Foot Infections. Int J Mol Sci 2021; 22:ijms222111552. [PMID: 34768982 DOI: 10.3390/ijms222111552.pmid:34768982;pmcid:pmc8584017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 10/16/2021] [Accepted: 10/20/2021] [Indexed: 05/27/2023] Open
Abstract
Diabetic foot infection is the leading cause of non-traumatic lower limb amputations worldwide. In addition, diabetes mellitus and sequela of the disease are increasing in prevalence. In 2017, 9.4% of Americans were diagnosed with diabetes mellitus (DM). The growing pervasiveness and financial implications of diabetic foot infection (DFI) indicate an acute need for improved clinical assessment and treatment. Complex pathophysiology and suboptimal specificity of current non-invasive imaging modalities have made diagnosis and treatment response challenging. Current anatomical and molecular clinical imaging strategies have mainly targeted the host's immune responses rather than the unique metabolism of the invading microorganism. Advances in imaging have the potential to reduce the impact of these problems and improve the assessment of DFI, particularly in distinguishing infection of soft tissue alone from osteomyelitis (OM). This review presents a summary of the known pathophysiology of DFI, the molecular basis of current and emerging diagnostic imaging techniques, and the mechanistic links of these imaging techniques to the pathophysiology of diabetic foot infections.
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Affiliation(s)
- Katie Rubitschung
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Amber Sherwood
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Andrew P Crisologo
- Department of Plastic Surgery, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA
| | - Kavita Bhavan
- Department of Internal Medicine, Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Robert W Haley
- Department of Internal Medicine, Epidemiology Division, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Dane K Wukich
- Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Laila Castellino
- Department of Internal Medicine, Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Helena Hwang
- Department of Pathology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Javier La Fontaine
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Avneesh Chhabra
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Lawrence Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Orhan K Öz
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
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Klein DA, Lee BH, Bezhani H, Droukas DD, Stoffels G. The Clinical Utility of MRI in Evaluating for Osteomyelitis in Patients Presenting with Uncomplicated Cellulitis. J Foot Ankle Surg 2021; 59:323-329. [PMID: 32130998 DOI: 10.1053/j.jfas.2019.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 02/11/2019] [Accepted: 02/18/2019] [Indexed: 02/03/2023]
Abstract
Magnetic resonance imaging (MRI) is vital in the diagnosis of osteomyelitis (OM) in patients presenting with cellulitis. Typically, cellulitis is treated with oral antibiotics; however, patients with concomitant OM may require long-term intravenous antibiotics or surgical intervention. We reviewed lower extremity MRIs in patients presenting with cellulitis and clinical concern for OM. We found 488 patient examinations spanning 5 years (2011 to 2016); 47 patients were excluded (final N = 441). Each MRI was interpreted by a radiologist to determine the rate of OM, abscess, ulceration, and imaging diagnosis of cellulitis. Concurrent assessment of the electronic medical record was performed to review patient demographics, the presence of abscess and/or ulceration, and comorbidities such as diabetes, hyperlipidemia (HLD), atherosclerotic disease, and peripheral vascular disease. Of the 441 lower extremity MRIs included, 170 (39%) were diagnosed with OM, 236 (54%) had ulcers, and 66 (15%) had abscesses. Age, laterality, and reporting physician were not statistically significant independent variables in the rate of reported OM. Diabetes and HLD/atherosclerotic disease were both statistically significant variables with regard to OM rates. Clinical documentation and MRI diagnosis of ulceration were both statistically significant variables in the rate of OM. Regression analysis determined that body part, ulceration, HLD/atherosclerosis, and sex were independent predictors of OM. In our study, of the population of patients with a high clinical suspicion for OM, 39% had OM diagnosed on MRI. However, the incidence of OM in uncomplicated cellulitis was only 11.8% compared with 43.9% in complicated cellulitis. When considering the forefoot alone, patients with ulceration at MRI were 5.6 times more likely to have underlying OM than those without.
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Affiliation(s)
- Devon A Klein
- Assistant Professor, Chief of Musculoskeletal Imaging, Department of Diagnostic Radiology, Lenox Hill Hospital, New York, NY.
| | - Brian H Lee
- Attending Radiologist, Red Bank Radiology, Red Bank, NJ
| | - Hariklia Bezhani
- Resident, Department of Diagnostic Radiology, Lenox Hill Hospital, New York, NY
| | - Daniel D Droukas
- Attending Podiatrist, Foot and Ankle Surgeons of New York, New York, NY
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Polk C, Sampson MM, Roshdy D, Davidson LE. Skin and Soft Tissue Infections in Patients with Diabetes Mellitus. Infect Dis Clin North Am 2020; 35:183-197. [PMID: 33303332 DOI: 10.1016/j.idc.2020.10.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Skin and soft tissue infections are common in diabetics. Diabetic foot infection usually results from disruption of the skin barrier, trauma, pressure, or ischemic wounds. These wounds may become secondarily infected or lead to development of adjacent soft tissue or deeper bone infection. Clinical assessment and diagnosis of these conditions using a multidisciplinary management approach, including careful attention to antibiotic selection, lead to the best outcomes in patient care.
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Affiliation(s)
- Christopher Polk
- Division of Infectious Diseases, Department of Medicine, Atrium Health, Charlotte, NC, USA
| | - Mindy M Sampson
- Division of Infectious Diseases, Department of Medicine, Atrium Health, Charlotte, NC, USA
| | - Danya Roshdy
- Antimicrobial Support Network, Division of Pharmacy, Atrium Health, 1000 Blythe Boulevard, Charlotte, NC 28203, USA
| | - Lisa E Davidson
- Division of Infectious Diseases, Department of Medicine, Atrium Health, 1540 Garden Terrace, Suite 211, Charlotte, NC 28203, USA.
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Llewellyn A, Jones-Diette J, Kraft J, Holton C, Harden M, Simmonds M. Imaging tests for the detection of osteomyelitis: a systematic review. Health Technol Assess 2020; 23:1-128. [PMID: 31670644 DOI: 10.3310/hta23610] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Osteomyelitis is an infection of the bone. Medical imaging tests, such as radiography, ultrasound, magnetic resonance imaging (MRI), single-photon emission computed tomography (SPECT) and positron emission tomography (PET), are often used to diagnose osteomyelitis. OBJECTIVES To systematically review the evidence on the diagnostic accuracy, inter-rater reliability and implementation of imaging tests to diagnose osteomyelitis. DATA SOURCES We conducted a systematic review of imaging tests to diagnose osteomyelitis. We searched MEDLINE and other databases from inception to July 2018. REVIEW METHODS Risk of bias was assessed with QUADAS-2 [quality assessment of diagnostic accuracy studies (version 2)]. Diagnostic accuracy was assessed using bivariate regression models. Imaging tests were compared. Subgroup analyses were performed based on the location and nature of the suspected osteomyelitis. Studies of children, inter-rater reliability and implementation outcomes were synthesised narratively. RESULTS Eighty-one studies were included (diagnostic accuracy: 77 studies; inter-rater reliability: 11 studies; implementation: one study; some studies were included in two reviews). One-quarter of diagnostic accuracy studies were rated as being at a high risk of bias. In adults, MRI had high diagnostic accuracy [95.6% sensitivity, 95% confidence interval (CI) 92.4% to 97.5%; 80.7% specificity, 95% CI 70.8% to 87.8%]. PET also had high accuracy (85.1% sensitivity, 95% CI 71.5% to 92.9%; 92.8% specificity, 95% CI 83.0% to 97.1%), as did SPECT (95.1% sensitivity, 95% CI 87.8% to 98.1%; 82.0% specificity, 95% CI 61.5% to 92.8%). There was similar diagnostic performance with MRI, PET and SPECT. Scintigraphy (83.6% sensitivity, 95% CI 71.8% to 91.1%; 70.6% specificity, 57.7% to 80.8%), computed tomography (69.7% sensitivity, 95% CI 40.1% to 88.7%; 90.2% specificity, 95% CI 57.6% to 98.4%) and radiography (70.4% sensitivity, 95% CI 61.6% to 77.8%; 81.5% specificity, 95% CI 69.6% to 89.5%) all had generally inferior diagnostic accuracy. Technetium-99m hexamethylpropyleneamine oxime white blood cell scintigraphy (87.3% sensitivity, 95% CI 75.1% to 94.0%; 94.7% specificity, 95% CI 84.9% to 98.3%) had higher diagnostic accuracy, similar to that of PET or MRI. There was no evidence that diagnostic accuracy varied by scan location or cause of osteomyelitis, although data on many scan locations were limited. Diagnostic accuracy in diabetic foot patients was similar to the overall results. Only three studies in children were identified; results were too limited to draw any conclusions. Eleven studies evaluated inter-rater reliability. MRI had acceptable inter-rater reliability. We found only one study on test implementation and no evidence on patient preferences or cost-effectiveness of imaging tests for osteomyelitis. LIMITATIONS Most studies included < 50 participants and were poorly reported. There was limited evidence for children, ultrasonography and on clinical factors other than diagnostic accuracy. CONCLUSIONS Osteomyelitis is reliably diagnosed by MRI, PET and SPECT. No clear reason to prefer one test over the other in terms of diagnostic accuracy was identified. The wider availability of MRI machines, and the fact that MRI does not expose patients to harmful ionising radiation, may mean that MRI is preferable in most cases. Diagnostic accuracy does not appear to vary with the potential cause of osteomyelitis or with the body part scanned. Considerable uncertainty remains over the diagnostic accuracy of imaging tests in children. Studies of diagnostic accuracy in children, particularly using MRI and ultrasound, are needed. STUDY REGISTRATION This study is registered as PROSPERO CRD42017068511. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 61. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Alexis Llewellyn
- Centre for Reviews and Dissemination, University of York, York, UK
| | | | | | | | - Melissa Harden
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Mark Simmonds
- Centre for Reviews and Dissemination, University of York, York, UK
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Imaging for detection of osteomyelitis in people with diabetic foot ulcers: A systematic review and meta-analysis. Eur J Radiol 2020; 131:109215. [PMID: 32862106 DOI: 10.1016/j.ejrad.2020.109215] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/09/2020] [Accepted: 08/08/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Osteomyelitis is an infection of the bone which can occur in people with diabetic foot ulcers. It can be diagnosed using X-rays, ultrasound, scintigraphy, magnetic resonance imaging (MRI), single photon emission computed tomography (SPECT) and positron emission tomography (PET). OBJECTIVES To review the evidence on the diagnostic accuracy of imaging tests to diagnose osteomyelitis in people with diabetic foot ulcers. METHODS We conducted a systematic review and meta-analysis. MEDLINE, EMBASE and other databases were searched to July 2018. Risk of bias was evaluated. Diagnostic accuracy was estimated using bivariate meta-analyses. RESULTS Thirty-six studies were included in the meta-analysis. Eight studies were at high risk of bias MRI had high diagnostic accuracy (22 studies: 96.4 % sensitivity (95 % CI 90.7-98.7); 83.8 % specificity (76.0-89.5)). PET scans also had high accuracy (6 studies: 84.3 % sensitivity (52.8-96.3); 92.8 % specificity (75.7-98.2)), and possibly also SPECT, but with few studies (3 studies: 95.6 % sensitivity (76.0-99.3); 55.1 % specificity (19.3-86.3)). Scintigraphy (17 studies: 84.2 % sensitivity (76.8-89.6); 67.7 % specificity (56.2-77.4)), and X-rays (16 studies: 61.9 % sensitivity (50.5-72.1); 78.3 % specificity (62.9-88.5)) had generally inferior diagnostic accuracy. CONCLUSIONS MRI and PET both reliably diagnose osteomyelitis in diabetic foot ulcer patients. SPECT may also have good diagnostic accuracy, although evidence is limited. This review confirms most current guidelines, showing that MRI may be the preferable test in most cases, given its wider availability and the lack of potentially harmful ionising radiation.
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Singer AD, Umpierrez M, Kakarala A, Schechter MC, Maceroli M, Sharma GB, Rajani RR. Performance of a rapid two-sequence screening protocol for osteomyelitis of the foot. Skeletal Radiol 2020; 49:977-984. [PMID: 31938864 DOI: 10.1007/s00256-019-03367-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 12/13/2019] [Accepted: 12/22/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Compare a two sequence protocol to a standard protocol in the detection of pedal osteomyelitis (OM) and abscesses and to identify patients that benefit from a full protocol. MATERIALS AND METHODS One hundred thirty-two foot MRIs ordered to assess for OM were enrolled, and the following items were extracted from the clinical reports: use of IV contrast, the presence of OM, reactive osteitis, and a soft tissue abscess. Using only one T1 nonfat-suppressed and one fluid sensitive fat-suppressed sequences, two experienced musculoskeletal radiologists reviewed each case for the presence of OM, reactive osteitis, or an abscess. A Kappa test was calculated to assess for interobserver agreement, and diagnostic performance was determined. The McNemar test was used to assess for the effect of contrast. RESULTS Agreement between both observers and the clinical report on the presence of osteomyelitis was substantial ( k = 0.63 and 0.72, p < 0.001), while the agreement for abscess was fair (k = 0.29 and 0.38, p < 0.001). For osteomyelitis, both observers showed good accuracy (0.85 and 0.86). When screening bone for a normal versus abnormal case, this method was highly sensitive (0.97-0.98), but was less sensitive for abscess (0.63-0.75). Fifty-one percent of exams used contrast, and it did impact the diagnosis of abscess for one observer. CONCLUSION This rapid protocol is accurate in making the diagnosis of OM, and its high sensitivity makes it useful to screen for patients that would benefit from a full protocol.
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Affiliation(s)
- Adam D Singer
- Department of Radiology and Imaging Sciences, Division of Musculoskeletal Imaging, Emory University Hospital, 59 Executive Park South, 4th Floor Suite 4009, Atlanta, GA, 30329, USA.
| | - Monica Umpierrez
- Department of Radiology and Imaging Sciences, Division of Musculoskeletal Imaging, Emory University Hospital, 59 Executive Park South, 4th Floor Suite 4009, Atlanta, GA, 30329, USA
| | - Aparna Kakarala
- Department of Radiology and Imaging Sciences, Division of Musculoskeletal Imaging, Emory University Hospital, 59 Executive Park South, 4th Floor Suite 4009, Atlanta, GA, 30329, USA
| | - Marcos C Schechter
- Department of Medicine, Division of Infectious Disease, Emory University Hospital, Atlanta, GA, USA
| | - Michael Maceroli
- Department of Orthopaedic Surgery, Emory University Hospital, Atlanta, GA, USA
| | | | - Ravi R Rajani
- Department of Surgery, Division of Vascular Surgery, Emory University Hospital, Atlanta, GA, USA
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Walker EA, Beaman FD, Wessell DE, Cassidy RC, Czuczman GJ, Demertzis JL, Lenchik L, Motamedi K, Pierce JL, Sharma A, Ying-Kou Yung E, Kransdorf MJ. ACR Appropriateness Criteria® Suspected Osteomyelitis of the Foot in Patients With Diabetes Mellitus. J Am Coll Radiol 2019; 16:S440-S450. [DOI: 10.1016/j.jacr.2019.05.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 05/16/2019] [Indexed: 12/16/2022]
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Mahendra M, Singh R. Diagnostic Accuracy and Surgical Utility of MRI in Complicated Diabetic Foot. J Clin Diagn Res 2017; 11:RC01-RC04. [PMID: 28892986 DOI: 10.7860/jcdr/2017/25902.10154] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Accepted: 04/27/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Diabetic foot complications pose a significant public health hazard and have negative effect on life quality. These complications are associated with increased risk of amputations and premature death. So focus is increasing on early treatment of complicated diabetic foot. AIM To assess the diagnostic accuracy and surgical utility of MRI in complicated diabetic foot. MATERIALS AND METHODS Thirty four complicated diabetic patients were evaluated prospectively. Initially x-ray was done and a provisional management plan was formulated. Later T1W, T2W and FSat sequences of the affected foot and ankle was carried out. The soft tissue, tendons and osseous apparatus were evaluated and subsequently compared with histopathological examination. Before and after MRI, change in management plan was marked. Previously operated cases with persistent ulcer of affected foot were excluded from the study. RESULTS Twenty two males and 12 females with mean age of 52±8.8 years were analysed. The sensitivity of MRI for tenosynovitis and osteomyelitis was 88% and 100% respectively. The specificity for the same was 100% and 90%. Of all 34 cases, MRI reshapes surgical planning in 23.5% cases (8 patients). The difference between MRI and histopathological findings was evaluated statistically using Fisher-Z test and the proportion of difference between these two groups was not significant as values for tenosynovitis was Z=0.50 (p-value >0.05) and for osteomyelitis Z= 0.54 (p-value>0.05). CONCLUSION The result indicates that MRI is a sensitive and accurate imaging modality for evaluation of diabetic foot and for planning proper treatment and the MRI correlates significantly with the surgical finding.
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Affiliation(s)
- Mayank Mahendra
- Assistant Professor, Department of Orthopaedics, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Rahul Singh
- Assistant Professor, Department of Orthopaedics, Mayo Institute of Medical Sciences, Barabanki, Uttar Pradesh, India
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Zaiton F, Samir AM, Elkamash TH, Tawfik AM, Hadhoud KM. Evaluation of diabetic foot osteomyelitis using probe to bone test and magnetic resonance imaging and their impact on surgical intervention. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2014. [DOI: 10.1016/j.ejrnm.2014.04.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Roug IK, Pierre-Jerome C. MRI spectrum of bone changes in the diabetic foot. Eur J Radiol 2011; 81:1625-9. [PMID: 21620598 DOI: 10.1016/j.ejrad.2011.04.048] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2011] [Accepted: 04/21/2011] [Indexed: 01/22/2023]
Abstract
PURPOSES (1) To assess the prevalence of bone marrow changes in the diabetic foot and (2) to discuss the clinical significance of these changes. METHODS 85 patients with radiographic and magnetic resonance imaging (MRI) foot examinations were selected. Inclusion criteria were clinical diagnosis of diabetes and bone changes on radiographs and MRI. The material was selected from the image storage (PACS) system. We searched for vascular (infarct and necrosis), traumatic (bruise and occult fractures), destruction and debris, dislocation, osteochondritis, osteomyelitis. Five patients had bilateral examinations. A total of 90 feet were evaluated. RESULTS From 90 feet, 17 (18.9%) presented with vascular changes, from them, 11 feet had infarct and 6 feet had necrosis. Twenty (22.2%) feet had traumatic changes; of them, 10 (50%) had edema on MRI. Five (25%) cases had occult fracture on MRI; and 5 (25%) had visible fracture on both X-ray and MRI. Bone destruction was detected in 8 (8.9%) feet. Bony debris was visualized in three of them. Bone dislocation was visualized in 11 (12.2%) feet. There was evidence of osteochondritis in twenty-four (26.7%) feet. Osteomyelitis was diagnosed in ten (11.1%) feet. CONCLUSION Diabetic foot is a challenge for both clinicians and radiologists due to its complexity. The bone derangements inherent to the diabetic foot can be evaluated with high accuracy with MRI.
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Schweitzer ME, Daffner RH, Weissman BN, Bennett DL, Blebea JS, Jacobson JA, Morrison WB, Resnik CS, Roberts CC, Rubin DA, Seeger LL, Taljanovic M, Wise JN, Payne WK. ACR Appropriateness Criteria® on Suspected Osteomyelitis in Patients With Diabetes Mellitus. J Am Coll Radiol 2008; 5:881-6. [DOI: 10.1016/j.jacr.2008.05.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2008] [Indexed: 11/28/2022]
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Abstract
People with diabetes develop foot ulcers because of neuropathy (sensory, motor, and autonomic deficits), ischaemia, or both. The initiating injury may be from acute mechanical or thermal trauma or from repetitively or continuously applied mechanical stress. Patients with clinically significant limb ischaemia should be assessed by a vascular surgeon to determine the need for angioplasty, stenting, or femorodistal bypass. When infection complicates a foot ulcer, the combination can be limb or life-threatening. Infection is defined clinically, but wound cultures reveal the causative pathogens. Tissue specimens are strongly preferred to wound swabs for wound cultures. Antimicrobial therapy should be guided by culture results, and should aim to cure the infection, not to heal the wound. Alleviation of the mechanical load on ulcers (off-loading) should always be a part of treatment. Neuropathic ulcers typically heal in 6 weeks with total contact casting, because it effectively relieves pressure at the ulcer site and enforces patient compliance. The success of other approaches to off-loading similarly depends on the patients' adherence to the effectiveness of pressure relief. Surgery to heal ulcers and prevent recurrence can include tenotomy, tendon lengthening, reconstruction, or removal of bony prominences. However, these procedures may result in secondary ulceration and other complications. Ulcer recurrence rates are high, but appropriate education for patients, the provision of posthealing footwear, and regular foot care can reduce rates of re-ulceration.
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Affiliation(s)
- Peter R Cavanagh
- Diabetic Foot Care Program, Department of Biomedical Engineering, and the Orthopaedic Research Center, Cleveland Clinic Foundation, Cleveland 44195, OH, USA.
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