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Taljanovic MS, Omar IM, Melville DM, Shultz CL, Klauser AS, Weaver JS. Imaging mimickers of MSK infection. Skeletal Radiol 2024:10.1007/s00256-024-04763-8. [PMID: 39150526 DOI: 10.1007/s00256-024-04763-8] [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: 10/02/2023] [Revised: 07/18/2024] [Accepted: 07/19/2024] [Indexed: 08/17/2024]
Abstract
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.
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Affiliation(s)
- M S Taljanovic
- Departments of Medical Imaging and Orthopaedic Surgery, The University of Arizona College of Medicine, 1501 N. Campbell Ave, Tucson, AZ, 85724, USA.
- Department of Radiology, University of New Mexico, MSC 10 5530, Albuquerque, NM, 87131, USA.
| | - I M Omar
- Department of Radiology, Northwestern Memorial Hospital, 676 N. Saint Clair Street, Suite 800, Chicago, IL, 60611, USA
| | - D M Melville
- Department of Radiology, Mayo Clinic Arizona, 5777 E. Mayo Boulevard, Phoenix, AZ, 85054, USA
| | - C L Shultz
- Department of Orthopaedics and Rehabilitation, University of New Mexico, MSC 10 5600, Albuquerque, NM, 87131, USA
| | - A S Klauser
- Department of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - J S Weaver
- Department of Radiology, University of Texas Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
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2
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Lauri C, Noriega-Álvarez E, Chakravartty RM, Gheysens O, Glaudemans AWJM, Slart RHJA, Kwee TC, Lecouvet F, Panagiotidis E, Zhang-Yin J, Martinez JLL, Lipsky BA, Uccioli L, Signore A. Diagnostic imaging of the diabetic foot: an EANM evidence-based guidance. Eur J Nucl Med Mol Imaging 2024; 51:2229-2246. [PMID: 38532027 PMCID: PMC11178575 DOI: 10.1007/s00259-024-06693-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/14/2024] [Indexed: 03/28/2024]
Abstract
PURPOSE Consensus on the choice of the most accurate imaging strategy in diabetic foot infective and non-infective complications is still lacking. This document provides evidence-based recommendations, aiming at defining which imaging modality should be preferred in different clinical settings. METHODS This working group includes 8 nuclear medicine physicians appointed by the European Association of Nuclear Medicine (EANM), 3 radiologists and 3 clinicians (one diabetologist, one podiatrist and one infectious diseases specialist) selected for their expertise in diabetic foot. The latter members formulated some clinical questions that are not completely covered by current guidelines. These questions were converted into statements and addressed through a systematic analysis of available literature by using the PICO (Population/Problem-Intervention/Indicator-Comparator-Outcome) strategy. Each consensus statement was scored for level of evidence and for recommendation grade, according to the Oxford Centre for Evidence-Based Medicine (OCEBM) criteria. RESULTS Nine clinical questions were formulated by clinicians and used to provide 7 evidence-based recommendations: (1) A patient with a positive probe-to-bone test, positive plain X-rays and elevated ESR should be treated for presumptive osteomyelitis (OM). (2) Advanced imaging with MRI and WBC scintigraphy, or [18F]FDG PET/CT, should be considered when it is needed to better evaluate the location, extent or severity of the infection, in order to plan more tailored treatment. (3) In a patient with suspected OM, positive PTB test but negative plain X-rays, advanced imaging with MRI or WBC scintigraphy + SPECT/CT, or with [18F]FDG PET/CT, is needed to accurately assess the extent of the infection. (4) There are no evidence-based data to definitively prefer one imaging modality over the others for detecting OM or STI in fore- mid- and hind-foot. MRI is generally the first advanced imaging modality to be performed. In case of equivocal results, radiolabelled WBC imaging or [18F]FDG PET/CT should be used to detect OM or STI. (5) MRI is the method of choice for diagnosing or excluding Charcot neuro-osteoarthropathy; [18F]FDG PET/CT can be used as an alternative. (6) If assessing whether a patient with a Charcot foot has a superimposed infection, however, WBC scintigraphy may be more accurate than [18F]FDG PET/CT in differentiating OM from Charcot arthropathy. (7) Whenever possible, microbiological or histological assessment should be performed to confirm the diagnosis. (8) Consider appealing to an additional imaging modality in a patient with persisting clinical suspicion of infection, but negative imaging. CONCLUSION These practical recommendations highlight, and should assist clinicians in understanding, the role of imaging in the diagnostic workup of diabetic foot complications.
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Affiliation(s)
- Chiara Lauri
- Inflammation and Infection Committee of the European Association of Nuclear Medicine (EANM), Vienna, Austria
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, Faculty of Medicine and Psychology, "Sapienza" University of Rome, Rome, Italy
| | - Edel Noriega-Álvarez
- Inflammation and Infection Committee of the European Association of Nuclear Medicine (EANM), Vienna, Austria
- Department of Nuclear Medicine and Molecular Imaging, University Hospital of Guadalajara, Guadalajara, Spain
| | - Riddhika M Chakravartty
- Inflammation and Infection Committee of the European Association of Nuclear Medicine (EANM), Vienna, Austria
- Radiology Department, Shrewsbury and Telford Hospitals NHS Trust, Shrewsbury, UK
| | - Olivier Gheysens
- Inflammation and Infection Committee of the European Association of Nuclear Medicine (EANM), Vienna, Austria
- Department of Nuclear Medicine and Molecular imaging, University Hospitals Leuven, Leuven, Belgium
| | - Andor W J M Glaudemans
- Inflammation and Infection Committee of the European Association of Nuclear Medicine (EANM), Vienna, Austria.
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
| | - Riemer H J A Slart
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
- Department of Biomedical Photonic Imaging, Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
| | - Thomas C Kwee
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Frédéric Lecouvet
- Department of Radiology, Institut de Recherche Expérimentale et Clinique Cliniques, Universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Emmanouil Panagiotidis
- Bone & Joint Committee of the European Association of Nuclear Medicine (EANM), Vienna, Austria
- Nuclear Medicine Department/PET CT, Theagenio Cancer Center, Thessaloniki, Greece
| | - Jules Zhang-Yin
- Bone & Joint Committee of the European Association of Nuclear Medicine (EANM), Vienna, Austria
- Department of Nuclear Medicine, Clinique Sud Luxembourg, Vivalia, Arlon, Belgium
| | | | - Benjamin A Lipsky
- Emeritus Professor of Medicine, University of Washington, Seattle, USA
- Green Templeton College, University of Oxford, Oxford, UK
| | - Luigi Uccioli
- Diabetes and Endocrinology Section, CTO Hospital of Rome, Rome, Italy
- Department of Biomedicine and prevention, Tor Vergata University, Rome, Italy
| | - Alberto Signore
- Inflammation and Infection Committee of the European Association of Nuclear Medicine (EANM), Vienna, Austria
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, Faculty of Medicine and Psychology, "Sapienza" University of Rome, Rome, Italy
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3
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Pal D, Roy SG, Singh R, Hayeri MR. Imaging features of soft-tissue infections. Skeletal Radiol 2024:10.1007/s00256-024-04694-4. [PMID: 38702530 DOI: 10.1007/s00256-024-04694-4] [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: 09/10/2023] [Revised: 04/07/2024] [Accepted: 04/22/2024] [Indexed: 05/06/2024]
Abstract
Skin and soft tissues are among the most common sites of infections. Infections can involve the superficial epidermis to deep muscles and bones. Most infections spread through contiguous structures, although hematogenous spread can occur in the setting of an immunocompromised state and with atypical infections. While clinical diagnosis of infections is possible, it often lacks specificity, necessitating the use of imaging for confirmation. Cross-sectional imaging with US, CT, and MRI is frequently performed not just for diagnosis, but to delineate the extent of infection and to aid in management. Nonetheless, the imaging features have considerable overlap, and as such, it is essential to integrate imaging features with clinical features for managing soft tissue infections. Radiologists must be aware of the imaging features of different infections and their mimics, as well as the pros and cons of each imaging technique to properly use them for appropriate clinical situations. In this review, we summarize the most recent evidence-based features of key soft tissue infections.
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Affiliation(s)
- Devpriyo Pal
- North Bengal Medical College, Siliguri, West Bengal, India
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Slim I, Ibrahim A, Andoulsi S, Beaulieu CA, Freire V. Non-Enhancing Tissue on Diabetic Foot Magnetic Resonance Imaging in Relation to Osteomyelitis Investigation: Magnetic Resonance Imaging Performance, Pitfalls and Clinical Considerations. Can Assoc Radiol J 2023; 74:705-712. [PMID: 37071144 DOI: 10.1177/08465371231167595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023] Open
Abstract
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.
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Affiliation(s)
- Inas Slim
- University of Montreal, Montreal, QC, Canada
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5
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Lee J, Forster BB. Non-Enhancing Tissue on Diabetic Foot Magnetic Resonance Imaging in Relation to Osteomyelitis Investigation: Magnetic Resonance Imaging Performance, Pitfalls and Clinical Considerations. Can Assoc Radiol J 2023; 74:618-619. [PMID: 37211654 DOI: 10.1177/08465371231179461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023] Open
Affiliation(s)
- Juvel Lee
- Department of Radiology, University of Ottawa, Ottawa, ON, Canada
| | - Bruce B Forster
- Department of Radiology, Vancouver General Hospital, Vancouver, BC, Canada
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6
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Jardon M, Alaia EF. Approach to imaging modalities in the setting of suspected infection. Skeletal Radiol 2023:10.1007/s00256-023-04478-2. [PMID: 37857751 DOI: 10.1007/s00256-023-04478-2] [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: 08/01/2023] [Revised: 10/03/2023] [Accepted: 10/04/2023] [Indexed: 10/21/2023]
Abstract
Imaging plays an important role in the workup of musculoskeletal infection, in conjunction with clinical history and physical exam. There are multiple imaging modalities that can be of clinical utility in the setting of suspected infection, each with their own benefits and limitations. Radiography is a low-cost, accessible modality providing a broad osseous overview, but can be insensitive for early osteomyelitis. Ultrasound plays a more limited role in the workup of musculoskeletal infection, but can be useful in the pediatric population or for real-time guidance for joint and soft tissue aspirations. Computed tomography (CT) plays an important role in the timely and accurate diagnosis of critically ill patients in the emergency setting. Its superior soft tissue characterization allows for diagnosis of abscesses, and it can help confirm the clinical diagnosis of necrotizing fasciitis when soft tissue gas is present. Magnetic resonance imaging (MRI) is often the modality of choice in the diagnosis of infection, as its superior contrast resolution allows for clear delineation of the presence and extent of both soft tissue infection and osteomyelitis. Additionally, the use of intravenous contrast and advanced imaging sequences such as diffusion weighted imaging (DWI) further increases the diagnostic utility of MRI in the assessment for infection. Familiarity with the diagnostic utility of each imaging modality will allow the radiologist to appropriately guide imaging workup in the setting of clinically suspected infection.
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Affiliation(s)
- Meghan Jardon
- Department of Radiology, NYU Langone Medical Center, New York, NY, USA.
| | - Erin F Alaia
- Department of Radiology, NYU Langone Medical Center, New York, NY, USA
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7
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Zaki I, Morrison WB. Osteomyelitis and Septic Arthritis of the Foot and Ankle: Imaging Update. Foot Ankle Clin 2023; 28:589-602. [PMID: 37536820 DOI: 10.1016/j.fcl.2023.05.009] [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] [Indexed: 08/05/2023]
Abstract
Radiography is considered the first-line screening exam for clinically suspected osteomyelitis. However, additional evaluation is generally needed. MRI is the definitive diagnostic exam with high sensitivity and specificity combined with excellent anatomic definition. Gadolinium contrast can be useful to detect areas of devitalization before surgery. Bone marrow edema on fluid-sensitive images and low signal intensity on T1-weighted images in the presence of secondary MRI findings, including ulcer, sinus tract, and cellulitis with or without abscess are typical findings of osteomyelitis. If MRI is contraindicated, three phase bone scan can be used. Early diagnosis and treatment is essential.
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Affiliation(s)
- Islam Zaki
- Department of Radiology, Benha University Hospital, El-Shaheed Farid Nada, Qism Banha, Al Qalyubia Governorate, Banha, Egypt
| | - William B Morrison
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Thomas Jefferson University Hospital, 1079a Main Building 132 South 10th Street, Philadelphia, PA 19107, USA.
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Garcia-Diez AI, Tomas Batlle X, Perissinotti A, Isern-Kebschull J, Del Amo M, Soler JC, Bartolome A, Bencardino JT. Imaging of the Diabetic Foot. Semin Musculoskelet Radiol 2023; 27:314-326. [PMID: 37230131 DOI: 10.1055/s-0043-1764386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | | | - Jenny Teresa Bencardino
- Division of Musculoskeletal Radiology, Department of Radiology, Penn Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Bajaj G, Chhabra A. Bone Marrow Changes and Lesions of Diabetic Foot and Ankle Disease: Conventional and Advanced Magnetic Resonance Imaging. Semin Musculoskelet Radiol 2023; 27:73-90. [PMID: 36868246 DOI: 10.1055/s-0043-1761494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
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.
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Affiliation(s)
- Gitanjali Bajaj
- Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Avneesh Chhabra
- Department Radiology and Orthopedic Surgery, UT Southwestern, Dallas, Texas.,Johns Hopkins University and Walton Centre for Neuroscience, Liverpool, United Kingdom.,University of Dallas, Irving, Texas
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10
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Porrino J, Liu X, Kani K, Lee H. Spectrum of imaging findings in soft-tissue necrosis. Emerg Radiol 2023; 30:217-223. [PMID: 36626029 DOI: 10.1007/s10140-023-02113-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023]
Abstract
Soft tissue necrosis can occur at different tissue levels, with numerous underlying causes. In this pictorial review, we highlight myonecrosis, and its accompanying stages, fat necrosis, devitalized soft tissue seen with infection, and necrotizing soft tissue infections. Imaging examples are provided with each entity.
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Affiliation(s)
- Jack Porrino
- Yale Radiology and Biomedical Imaging, 330 Cedar Street, New Haven, CT, 06520, USA.
| | - Xiaozhou Liu
- Yale Radiology and Biomedical Imaging, 330 Cedar Street, New Haven, CT, 06520, USA
| | - Kimia Kani
- Department of Radiology, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD, 21201, USA
| | - Hyojeong Lee
- Yale Radiology and Biomedical Imaging, 330 Cedar Street, New Haven, CT, 06520, USA
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11
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Abikhzer G, Le H, Israel O. Hybrid imaging of Diabetic Foot Infections. Semin Nucl Med 2023; 53:86-97. [PMID: 36089528 DOI: 10.1053/j.semnuclmed.2022.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 08/15/2022] [Indexed: 01/28/2023]
Abstract
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.
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Affiliation(s)
- Gad Abikhzer
- Department of Radiology and Nuclear Medicine, Jewish General Hospital, Montreal, Quebec, Canada; Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada.
| | - Huy Le
- Department of Radiology and Nuclear Medicine, Jewish General Hospital, Montreal, Quebec, Canada; Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Ora Israel
- B. and R. Rapaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
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Teh J, Sharp R, McKean D. Presurgical Perspective and Postsurgical Evaluation of the Diabetic Foot. Semin Musculoskelet Radiol 2022; 26:717-729. [PMID: 36791740 DOI: 10.1055/s-0042-1760219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Management of the diabetic foot is complex and challenging, requiring a multidisciplinary approach. Imaging plays an important role in the decision-making process regarding surgery. This article discusses the presurgical perspective and postsurgical evaluation of the diabetic foot.
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Affiliation(s)
- James Teh
- Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Robert Sharp
- Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - David McKean
- Stoke Mandeville Hospital Buckinghamshire Healthcare NHS Trust
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13
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Mandell JC, Khurana B. Musculoskeletal Trauma and Infection. Magn Reson Imaging Clin N Am 2022; 30:441-454. [PMID: 35995472 DOI: 10.1016/j.mric.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
MR is often the most definitive imaging for assessment of musculoskeletal trauma and infection. Although it is not possible to address all the intricacies of these complex topics in a single article, this review will attempt to provide a useful toolbox of skills by discussing several common clinical scenarios faced by emergency radiologists in interpretation of adult trauma and infection. These scenarios include MR assessment of hip and pelvic fracture, traumatic soft tissue injuries, septic arthritis, soft tissue infection, and osteomyelitis.
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Affiliation(s)
- Jacob C Mandell
- Musculoskeletal Imaging and Intervention, Division of Musculoskeletal Radiology, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
| | - Bharti Khurana
- Division of Emergency Radiology, Brigham and Women's Hospital, Trauma Imaging Research and Innovation Center, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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14
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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: 0] [Impact Index Per Article: 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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15
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La Fontaine J, Bhavan K, Jupiter D, Lavery LA, Chhabra A. Magnetic Resonance Imaging of Diabetic Foot Osteomyelitis: Imaging Accuracy in Biopsy-Proven Disease. J Foot Ankle Surg 2021; 60:17-20. [PMID: 33214100 DOI: 10.1053/j.jfas.2020.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 01/30/2020] [Accepted: 02/09/2020] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Javier La Fontaine
- Professor, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
| | - Kavita Bhavan
- Assistant Professor, Department of Infectious Diseases, University of Texas Southwestern Medical Center, Dallas, TX
| | - Daniel Jupiter
- Associate Professor, Department of Preventive Medicine and Community Health, UT Medical Branch, Galveston, TX
| | - Lawrence A Lavery
- Professor, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Avneesh Chhabra
- Associate Professor, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX
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Abstract
AbstractMusculoskeletal infection can be an urgent or emergent clinical issue. Accurate imaging diagnosis is an essential part of the treatment algorithm. This review addresses advantages of available imaging modalities and radiologic appearance of the various manifestations of infection. Controversies are addressed, including the use of the term “osteitis.” Finally, the differential diagnosis of infection is reviewed, such as inflammatory arthropathies and tumors that can simulate infection on imaging exams.
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Abstract
The Society of Skeletal Radiology (SSR) Practice Guidelines and Technical Standards Committee identified musculoskeletal infection as a White Paper topic, and selected a Committee, tasked with developing a consensus on nomenclature for MRI of musculoskeletal infection outside the spine. The objective of the White Paper was to critically assess the literature and propose standardized terminology for imaging findings of infection on MRI, in order to improve both communication with clinical colleagues and patient care.A definition was proposed for each term; debate followed, and the committee reached consensus. Potential controversies were raised, with formulated recommendations. The committee arrived at consensus definitions for cellulitis, soft tissue abscess, and necrotizing infection, while discouraging the nonspecific term phlegmon. For bone infection, the term osteitis is not useful; the panel recommends using terms that describe the likelihood of osteomyelitis in cases where definitive signal changes are lacking. The work was presented virtually to SSR members, who had the opportunity for review and modification prior to submission for publication.
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Gurgitano M, Signorelli G, Rodà GM, Liguori A, Pandolfi M, Granata G, Arrichiello A, Ierardi AM, Paolucci A, Carrafiello G. Use of perfusional CBCT imaging for intraprocedural evaluation of endovascular treatment in patients with diabetic foot: a concept paper. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:e2020008. [PMID: 33245064 PMCID: PMC8023083 DOI: 10.23750/abm.v91i10-s.10267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 09/23/2020] [Indexed: 12/01/2022]
Abstract
Diabetes mellitus (DM) is one of the most common metabolic diseases worldwide; its global burden has increased rapidly over the past decade, enough to be considered a public health emergency in many countries. Diabetic foot disease and, particularly diabetic foot ulceration, is the major complication of DM: through a skin damage of the foot, with a loss of epithelial tissue, it can deepen to muscles and bones and lead to the amputation of the lower limbs. Peripheral arterial disease (PAD) in patients with diabetes, manifests like a diffuse macroangiopathic multi-segmental involvement of the lower limb vessels, also connected to a damage of collateral circulation; it may also display characteristic microaneurysms and tortuosity in distal arteries. As validation method, Bold-MRI is used. The diabetic foot should be handled with a multidisciplinary team approach, as its management requires systemic and localized treatments, pain control, monitoring of cardiovascular risk factors and other comorbidities. CBCT is an emerging medical imaging technique with the original feature of divergent radiation, forming a cone, in contrast with the spiral slicing of conventional CT, and has become increasingly important in treatment planning and diagnosis: from small anatomical areas, such as implantology, to the world of interventional radiology, with a wide range of applications: as guidance for biopsies or ablation treatments. The aim of this project is to evaluate the usefulness of perfusion CBCT imaging, obtained during endovascular revascularization, for intraprocedural evaluation of endovascular treatment in patients with diabetic foot. (www.actabiomedica.it).
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Affiliation(s)
- Martina Gurgitano
- Division of Radiology, IEO European institute of oncology IRCCS, Milan, Italy.
| | - Giulia Signorelli
- Postgraduation School in Radiodiagnostics, Università degli Studi di Milano, Milan, Italy Via Festa del Perdono 7, 20122, Milan, Italy.
| | - Giovanni Maria Rodà
- Postgraduation School in Radiodiagnostics, Università degli studi di Milano, via Festa del Perdono, 20122, Milan, Italy.
| | - Alessandro Liguori
- Operative Unit of Radiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy. Via Francesco Sforza 35, 20122, Milano, Italy.
| | - Marco Pandolfi
- Radiology Unit, Istituto Clinico Città Studi Milano, via Niccolò Jommelli, 17, 20131 Milano, Italy.
| | - Giuseppe Granata
- Postgraduation School in Radiodiagnostics, Università degli Studi di Milano, Milan, Italy Via Festa del Perdono 7, 20122, Milan, Italy.
| | - Antonio Arrichiello
- Postgraduation School in Radiodiagnostics, Università degli Studi di Milano, Milan, Italy Via Festa del Perdono 7, 20122, Milan, Italy.
| | - Anna Maria Ierardi
- Operative Unit of Radiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy. Via Francesco Sforza 35, 20122, Milano, Italy.
| | - Aldo Paolucci
- Operative Unit of Neuroradiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy.
| | - Gianpaolo Carrafiello
- Operative Unit of Radiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy. Via Francesco Sforza 35, 20122, Milano, Italy; Department of Health Sciences, Università degli studi di Milano, Milan, Italy.
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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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Lauri C, Glaudemans AW, Campagna G, Keidar Z, Muchnik Kurash M, Georga S, Arsos G, Noriega-Álvarez E, Argento G, Kwee TC, Slart RH, Signore A. Comparison of White Blood Cell Scintigraphy, FDG PET/CT and MRI in Suspected Diabetic Foot Infection: Results of a Large Retrospective Multicenter Study. J Clin Med 2020; 9:jcm9061645. [PMID: 32486304 PMCID: PMC7356770 DOI: 10.3390/jcm9061645] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/21/2020] [Accepted: 05/26/2020] [Indexed: 12/16/2022] Open
Abstract
Diabetic foot infections (DFIs) represent one of the most frequent and disabling morbidities of longstanding diabetes; therefore, early diagnosis is mandatory. The aim of this multicenter retrospective study was to compare the diagnostic accuracy of white blood cell scintigraphy (WBC), 18F-fluorodeoxyglucose positron emission tomography/computed tomography ((18F) FDG PET/CT), and Magnetic Resonance Imaging (MRI) in patients with suspected DFI. Images and clinical data from 251 patients enrolled by five centers were collected in order to calculate the sensitivity, specificity, and accuracy of WBC, FDG, and MRI in diagnosing osteomyelitis (OM), soft-tissue infection (STI), and Charcot osteoarthropathy. In OM, WBC acquired following the European Society of Nuclear Medicine (EANM) guidelines was more specific and accurate than MRI (91.9% vs. 70.7%, p < 0.0001 and 86.2% vs. 67.1%, p = 0.003, respectively). In STI, both FDG and WBC achieved a significantly higher specificity than MRI (97.9% and 95.7% vs. 83.6%, p = 0.04 and p = 0.018, respectively). In Charcot, both MRI and WBC demonstrated a significantly higher specificity and accuracy than FDG (88.2% and 89.3% vs. 62.5%, p = 0.0009; 80.3% and 87.9% vs. 62.1%, p < 0.02, respectively). Moreover, in Charcot, WBC was more specific than MRI (89.3% vs. 88.2% p < 0.0001). Given the limitations of a retrospective study, WBC using EANM guidelines was shown to be the most reliable imaging modality to differentiate between OM, STI, and Charcot in patients with suspected DFI.
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Affiliation(s)
- Chiara Lauri
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, “Sapienza” University of Rome, 00161 Rome, Italy; (C.L.); (G.C.)
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, 9700 Groningen, The Netherlands; (A.W.J.M.G.); (T.C.K.); (R.H.J.A.S.)
| | - Andor W.J.M. Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, 9700 Groningen, The Netherlands; (A.W.J.M.G.); (T.C.K.); (R.H.J.A.S.)
| | - Giuseppe Campagna
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, “Sapienza” University of Rome, 00161 Rome, Italy; (C.L.); (G.C.)
| | - Zohar Keidar
- Department of Nuclear Medicine, Rambam Health Care Campus, 3109601 Haifa, Israel; (Z.K.); (M.M.K.)
| | - Marina Muchnik Kurash
- Department of Nuclear Medicine, Rambam Health Care Campus, 3109601 Haifa, Israel; (Z.K.); (M.M.K.)
| | - Stamata Georga
- 3rd Department of Nuclear Medicine, Aristotle University Medical School, Papageorgiou General Hospital, 56403 Thessaloniki, Greece; (S.G.); (G.A.)
| | - Georgios Arsos
- 3rd Department of Nuclear Medicine, Aristotle University Medical School, Papageorgiou General Hospital, 56403 Thessaloniki, Greece; (S.G.); (G.A.)
| | - Edel Noriega-Álvarez
- Department of Nuclear Medicine, University Hospital of Ciudad Real, 13005 Ciudad Real, Spain;
| | - Giuseppe Argento
- Radiology Unit, Sant’Andrea University Hospital, 00189 Rome, Italy;
| | - Thomas C. Kwee
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, 9700 Groningen, The Netherlands; (A.W.J.M.G.); (T.C.K.); (R.H.J.A.S.)
| | - Riemer H.J.A. Slart
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, 9700 Groningen, The Netherlands; (A.W.J.M.G.); (T.C.K.); (R.H.J.A.S.)
- Department of Biomedical Photonic Imaging, Faculty of Science and Technology, University of Twente, 7500 Enschede, The Netherlands
| | - Alberto Signore
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, “Sapienza” University of Rome, 00161 Rome, Italy; (C.L.); (G.C.)
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, 9700 Groningen, The Netherlands; (A.W.J.M.G.); (T.C.K.); (R.H.J.A.S.)
- Correspondence: ; Tel.: +39-06-3377-6191
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Sherlock C, Fairburn A, Lawson A, Mair T. The use of magnetic resonance imaging for the assessment of distal limb wounds in horses: A pilot study. EQUINE VET EDUC 2019. [DOI: 10.1111/eve.13122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - A. Lawson
- Bell Equine Veterinary Clinic Mereworth UK
- Institute of Veterinary Science University of Liverpool Neston UK
| | - T. Mair
- Bell Equine Veterinary Clinic Mereworth UK
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Nguyen JC, Yi PH, Woo KM, Rosas HG. Detection of pediatric musculoskeletal pathology using the fluid-sensitive sequence. Pediatr Radiol 2019; 49:114-121. [PMID: 30232532 DOI: 10.1007/s00247-018-4256-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 07/18/2018] [Accepted: 08/31/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Musculoskeletal complaints are common among children, and magnetic resonance (MR) is increasingly used to supplement the clinical assessment. The validation of a short triage protocol could reduce the number of unnecessary contrast-enhanced MR studies that sometimes also require the need for sedation. OBJECTIVE To compare the diagnostic accuracy between fluid-sensitive sequence and contrast-enhanced MR study in the detection of musculoskeletal pathology in the pelvis and the appendicular skeleton in children older than 2 years. MATERIALS AND METHODS We performed a retrospective review between Feb. 1, 2016, and Oct. 31, 2016, and identified 99 studies from 96 patients (48 boys and 48 girls; mean age ± standard deviation, 11.1±4.6 years) without syndromic deformity, recent trauma, a history of infectious or inflammatory arthropathy, prior instrumentation or incomplete records. Two radiologists reviewed each study twice, at least 1 month apart, first using only the fluid-sensitive sequences (triage study) and later using the contrast-enhanced study. Readers rated the presence or absence of pathology independently and generated final impressions in consensus. We used Cohen's kappa (κ) and percentage agreement to compare agreement between readers and between studies, respectively. RESULTS Inter-reader agreement was overall higher for the contrast-enhanced studies (κ range = 0.91-1) than for the triage studies (κ range = 0.49-1). Percentage agreement between studies was high for the detection of pathology (97-100%) and for the impressions (93%). Clinical diagnoses were stress reaction or overuse in 31%, infection in 21%, space-occupying process in 17%, normal in 15%, inflammatory in 14%, and both inflammatory and overuse in 1%. The full study increased diagnostic confidence in five studies and accuracy in two but did not alter management. CONCLUSION The fluid-sensitive sequence had a near-perfect percentage of agreement with the contrast-enhanced study in the detection of musculoskeletal pathology and could possibly be used to screen children who need a contrast-enhanced MR study.
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Affiliation(s)
- Jie C Nguyen
- Department of Radiology, 3NW39, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.
| | - Paul H Yi
- Department of Radiology, Johns Hopkins University, Baltimore, MD, USA
| | - Kaitlin M Woo
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Humberto G Rosas
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Aragón-Sánchez J, Lipsky BA. Modern management of diabetic foot osteomyelitis. The when, how and why of conservative approaches. Expert Rev Anti Infect Ther 2017; 16:35-50. [PMID: 29231774 DOI: 10.1080/14787210.2018.1417037] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Diabetic foot osteomyelitis (DFO) has long been considered a complex infection that is both difficult to diagnose and treat, and is associated with a high rate of relapse and limb loss. Areas covered: DFO can usually be diagnosed by a combination of clinical evaluation, serum inflammatory markers and plain X-ray. When the results of these procedures are negative or contradictory, advanced imaging tests or bone biopsy may be necessary. Staphylococcus aureus remains the most frequent microorganism isolated from bone specimens, but infection is often polymicrobial. Antibiotic therapy, preferably with oral agents guided by results of bone culture, for a duration of no more than six weeks, appears to be as safe and effective as surgery in cases of uncomplicated forefoot DFO. Surgery (which should be limb-sparing when possible) is always required for DFO accompanied by necrotizing fasciitis, deep abscess, gangrene or in cases not responding (either clinically or radiographically) to apparently appropriate antibiotic treatment. Expert commentary: Research in the past decade has improved diagnosis and treatment of DFO, and most cases can now be managed with a 'conservative' approach, defined as treatment either exclusively with antibiotics or with surgery removing as little bone and soft tissue as necessary.
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Affiliation(s)
- Javier Aragón-Sánchez
- a Department of Surgery, Diabetic Foot Unit , La Paloma Hospital , Las Palmas de Gran Canaria , Spain
| | - Benjamin A Lipsky
- b Department of Medicine , University of Washington School of Medicine , Seattle , WA , USA.,c Green Templeton College , University of Oxford , Oxford , UK
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Mandell JC, Khurana B, Smith JT, Czuczman GJ, Ghazikhanian V, Smith SE. Osteomyelitis of the lower extremity: pathophysiology, imaging, and classification, with an emphasis on diabetic foot infection. Emerg Radiol 2017; 25:175-188. [DOI: 10.1007/s10140-017-1564-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 10/11/2017] [Indexed: 12/26/2022]
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Martín Noguerol T, Luna Alcalá A, Beltrán LS, Gómez Cabrera M, Broncano Cabrero J, Vilanova JC. Advanced MR Imaging Techniques for Differentiation of Neuropathic Arthropathy and Osteomyelitis in the Diabetic Foot. Radiographics 2017; 37:1161-1180. [DOI: 10.1148/rg.2017160101] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Teodoro Martín Noguerol
- From the MRI Section, Department of Radiology, SERCOSA, Health Time, Calle Carmelo Torres 2, 23007 Jaén, Spain (T.M.N., A.L.A.); Department of Radiology, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio (A.L.A.); Department of Radiology, NYU Langone Medical Center, New York, NY (L.S.B.); MRI Section, Department of Radiology, DADISA, Health Time, Cádiz, Spain (M.G.C.); MRI Section, Department of Radiology, RESSALTA, Health Time, Córdoba, Spain (J.B.C.); and Department of
| | - Antonio Luna Alcalá
- From the MRI Section, Department of Radiology, SERCOSA, Health Time, Calle Carmelo Torres 2, 23007 Jaén, Spain (T.M.N., A.L.A.); Department of Radiology, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio (A.L.A.); Department of Radiology, NYU Langone Medical Center, New York, NY (L.S.B.); MRI Section, Department of Radiology, DADISA, Health Time, Cádiz, Spain (M.G.C.); MRI Section, Department of Radiology, RESSALTA, Health Time, Córdoba, Spain (J.B.C.); and Department of
| | - Luis S. Beltrán
- From the MRI Section, Department of Radiology, SERCOSA, Health Time, Calle Carmelo Torres 2, 23007 Jaén, Spain (T.M.N., A.L.A.); Department of Radiology, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio (A.L.A.); Department of Radiology, NYU Langone Medical Center, New York, NY (L.S.B.); MRI Section, Department of Radiology, DADISA, Health Time, Cádiz, Spain (M.G.C.); MRI Section, Department of Radiology, RESSALTA, Health Time, Córdoba, Spain (J.B.C.); and Department of
| | - Marta Gómez Cabrera
- From the MRI Section, Department of Radiology, SERCOSA, Health Time, Calle Carmelo Torres 2, 23007 Jaén, Spain (T.M.N., A.L.A.); Department of Radiology, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio (A.L.A.); Department of Radiology, NYU Langone Medical Center, New York, NY (L.S.B.); MRI Section, Department of Radiology, DADISA, Health Time, Cádiz, Spain (M.G.C.); MRI Section, Department of Radiology, RESSALTA, Health Time, Córdoba, Spain (J.B.C.); and Department of
| | - Jordi Broncano Cabrero
- From the MRI Section, Department of Radiology, SERCOSA, Health Time, Calle Carmelo Torres 2, 23007 Jaén, Spain (T.M.N., A.L.A.); Department of Radiology, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio (A.L.A.); Department of Radiology, NYU Langone Medical Center, New York, NY (L.S.B.); MRI Section, Department of Radiology, DADISA, Health Time, Cádiz, Spain (M.G.C.); MRI Section, Department of Radiology, RESSALTA, Health Time, Córdoba, Spain (J.B.C.); and Department of
| | - Joan C. Vilanova
- From the MRI Section, Department of Radiology, SERCOSA, Health Time, Calle Carmelo Torres 2, 23007 Jaén, Spain (T.M.N., A.L.A.); Department of Radiology, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio (A.L.A.); Department of Radiology, NYU Langone Medical Center, New York, NY (L.S.B.); MRI Section, Department of Radiology, DADISA, Health Time, Cádiz, Spain (M.G.C.); MRI Section, Department of Radiology, RESSALTA, Health Time, Córdoba, Spain (J.B.C.); and Department of
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26
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McCarthy E, Morrison WB, Zoga AC. MR Imaging of the Diabetic Foot. Magn Reson Imaging Clin N Am 2017; 25:183-194. [DOI: 10.1016/j.mric.2016.08.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Leone A, Cassar-Pullicino VN, Semprini A, Tonetti L, Magarelli N, Colosimo C. Neuropathic osteoarthropathy with and without superimposed osteomyelitis in patients with a diabetic foot. Skeletal Radiol 2016; 45:735-54. [PMID: 26883537 DOI: 10.1007/s00256-016-2339-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Revised: 01/10/2016] [Accepted: 01/17/2016] [Indexed: 02/02/2023]
Abstract
Soft tissue and bone infection involving the foot is one of the most common long-term complications of diabetes mellitus, implying a serious impairment in quality of life for patients in the advanced stages of the disease. Neuropathic osteoarthropathy often coexists and differentiating between these two entities is commonly challenging, but crucial, as the management may differ substantially. The importance of correct diagnosis cannot be understated and effective management requires a multidisciplinary approach owing to the complicated nature of therapy in such patients. A missed diagnosis has a high likelihood of major morbidity for the patient, including limb amputation, and over-diagnosis results in a great socioeconomic challenge for healthcare systems, the over-utilization of healthcare resources, and the unwise use of antibiotics. Diagnosis is largely based on clinical signs supplemented by various imaging modalities such as radiography, MR imaging, and hybrid imaging techniques such as F-18 fluorodeoxyglucose-positron emission tomography. In the interests of the management of diabetic foot complications, this review article is aimed on the one hand at providing radiologists with important clinical knowledge, and on the other hand to equip clinicians with relevant radiological semiotics.
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Affiliation(s)
- Antonio Leone
- Institute of Radiology, School of Medicine, Catholic University, Largo A. Gemelli 1, 00168, Rome, Italy.
| | - Victor N Cassar-Pullicino
- Department of Diagnostic Imaging, The Robert Jones and Agnes Hunt Orthopaedic and District Hospital, Oswestry, Shropshire, UK
| | - Alessia Semprini
- Institute of Radiology, School of Medicine, Catholic University, Largo A. Gemelli 1, 00168, Rome, Italy
| | - Laura Tonetti
- Institute of Radiology, School of Medicine, Catholic University, Largo A. Gemelli 1, 00168, Rome, Italy
| | - Nicola Magarelli
- Institute of Radiology, School of Medicine, Catholic University, Largo A. Gemelli 1, 00168, Rome, Italy
| | - Cesare Colosimo
- Institute of Radiology, School of Medicine, Catholic University, Largo A. Gemelli 1, 00168, Rome, Italy
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Low KTA, Peh WCG. Magnetic resonance imaging of diabetic foot complications. Singapore Med J 2016; 56:23-33; quiz 34. [PMID: 25640096 DOI: 10.11622/smedj.2015006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
This pictorial review aims to illustrate the various manifestations of the diabetic foot on magnetic resonance (MR) imaging. The utility of MR imaging and its imaging features in the diagnosis of pedal osteomyelitis are illustrated. There is often difficulty encountered in distinguishing osteomyelitis from neuroarthropathy, both clinically and on imaging. By providing an accurate diagnosis based on imaging, the radiologist plays a significant role in the management of patients with complications of diabetic foot.
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Affiliation(s)
- Keynes T A Low
- Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Alexandra Health, 90 Yishun Central, Singapore 768828.
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Naidoo P, Liu VJ, Mautone M, Bergin S. Lower limb complications of diabetes mellitus: a comprehensive review with clinicopathological insights from a dedicated high-risk diabetic foot multidisciplinary team. Br J Radiol 2015; 88:20150135. [PMID: 26111070 DOI: 10.1259/bjr.20150135] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Diabetic complications in the lower extremity are associated with significant morbidity and mortality, and impact heavily upon the public health system. Early and accurate recognition of these abnormalities is crucial, enabling the early initiation of treatments and thus avoiding or minimizing deformity, dysfunction and amputation. Following careful clinical assessment, radiological imaging is central to the diagnostic and follow-up process. We aim to provide a comprehensive review of diabetic lower limb complications designed to assist radiologists and to contribute to better outcomes for these patients.
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Affiliation(s)
- P Naidoo
- 1 Monash University, Diagnostic Imaging Department, Monash Health, Clayton, VIC, Australia
| | - V J Liu
- 2 Department of Radiology, St George Hospital, Kogarah, NSW, Australia
| | - M Mautone
- 3 Diagnostic Imaging Department, Monash Health, Clayton, VIC, Australia
| | - S Bergin
- 4 Department of Podiatry, Monash Health, Clayton, VIC, Australia
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La Fontaine J, Bhavan K, Talal TK, Lavery LA. Current concepts in the surgical management of acute diabetic foot infections. Foot (Edinb) 2014; 24:123-7. [PMID: 25037559 DOI: 10.1016/j.foot.2014.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Revised: 05/22/2014] [Accepted: 05/25/2014] [Indexed: 02/04/2023]
Abstract
Diabetic foot complications are common, costly, and difficult to treat. Peripheral neuropathy, repetitive trauma, and peripheral vascular disease are common reasons that lead to ulcers, infection, and hospitalization. Individuals with diabetes presenting with foot infection require optimal medical and surgical management to accomplish limb salvage and prevent amputation; aggressive short-term and meticulous long-term care plans are required. Multiple classification systems have been recommended to ease the understanding and the management of these infections. Multi-disciplinary approach is the mainstay for a successful management. Such teams typically include multiple medical, surgical, and nursing specialties across a variety of public and private health care systems. This article is an overview in how to medically and surgically approach the diabetic foot infection with emphasis in soft tissue infection.
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Affiliation(s)
- Javier La Fontaine
- University of Texas Southwestern Medical Center, Department of Plastic Surgery, Dallas, TX, United States.
| | - Kavita Bhavan
- University of Texas Southwestern Medical Center, Department of Medicine, Infectious Disease, Dallas, TX, United States
| | - Talal K Talal
- Hamad Medical Corporation, Department of Medicine, Diabetic Foot and Wound Care Center, Doha, Qatar
| | - Lawrence A Lavery
- University of Texas Southwestern Medical Center, Department of Plastic Surgery, Dallas, TX, United States
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Maderal AD, Vivas AC, Zwick TG, Kirsner RS. Diabetic foot ulcers: evaluation and management. Hosp Pract (1995) 2014; 40:102-15. [PMID: 23086099 DOI: 10.3810/hp.2012.08.994] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Diabetic foot ulcers (DFUs) are a common complication of diabetes and present a significant health risk to patients, as well as impose a large economic burden. Evaluation for contributory factors that may impact general health or healing, such as hyperglycemia, peripheral artery disease, neuropathy, and nutritional status, is of the utmost importance. Management of DFUs requires involvement of a multidisciplinary team and a standardized approach to patient care. Standard therapy for DFUs includes offloading and debridement. Assessment and control of infection are critical, including determining the severity of the infection, which may drive therapeutic approaches. For recalcitrant ulcers, adjuvant therapies are used to hasten the healing process, and newer therapies are under investigation.
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Affiliation(s)
- Andrea D Maderal
- Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL
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Werpy N. The use of magnetic resonance imaging for the diagnosis of osteomyelitis. EQUINE VET EDUC 2013. [DOI: 10.1111/eve.12118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- N. Werpy
- Diagnostic Imaging Department; University of Florida; Gainesville Florida USA
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Treglia G, Sadeghi R, Annunziata S, Zakavi SR, Caldarella C, Muoio B, Bertagna F, Ceriani L, Giovanella L. Diagnostic performance of Fluorine-18-Fluorodeoxyglucose positron emission tomography for the diagnosis of osteomyelitis related to diabetic foot: a systematic review and a meta-analysis. Foot (Edinb) 2013; 23:140-8. [PMID: 23906976 DOI: 10.1016/j.foot.2013.07.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Revised: 07/01/2013] [Accepted: 07/04/2013] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To systematically review and meta-analyse published data about the diagnostic performance of Fluorine-18-Fluorodeoxyglucose ((18)F-FDG) positron emission tomography (PET) and PET/computed tomography (PET/CT) in osteomyelitis related to diabetic foot. METHODS A comprehensive literature search of studies on (18)F-FDG-PET and PET/CT in patients with diabetic foot was performed. Pooled sensitivity, specificity, positive and negative likelihood ratio (LR+ and LR-) and diagnostic odds ratio (DOR) and area under the summary ROC curve of (18)F-FDG-PET and PET/CT in patients with osteomyelitis related to diabetic foot were calculated. RESULTS Nine studies comprising 299 patients with diabetic foot were included in the qualitative analysis (systematic review) and discussed. The quantitative analysis (meta-analysis) of four selected studies provided the following results on a per patient-based analysis: sensitivity was 74% [95% confidence interval (95%CI): 60-85%], specificity 91% (95%CI: 85-96%), LR+ 5.56 (95%CI: 2.02-15.27), LR- 0.37 (95%CI: 0.10-1.35), and DOR 16.96 (95%CI: 2.06-139.66). The area under the summary ROC curve was 0.874. CONCLUSIONS In patients with suspected osteomyelitis related to diabetic foot (18)F-FDG-PET and PET/CT demonstrated a high specificity, being potentially useful tools if combined with other imaging methods such as MRI. Nevertheless, the literature focusing on the use of (18)F-FDG-PET and PET/CT in this setting remains still limited.
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Affiliation(s)
- Giorgio Treglia
- Department of Nuclear Medicine and PET/CT Center, Ente Ospedaliero Cantonale, Bellinzona, Switzerland.
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Abstract
Foot infections are common in persons with diabetes mellitus. Most diabetic foot infections occur in a foot ulcer, which serves as a point of entry for pathogens. Unchecked, infection can spread contiguously to involve underlying tissues, including bone. A diabetic foot infection is often the pivotal event leading to lower extremity amputation, which account for about 60% of all amputations in developed countries. Given the crucial role infections play in the cascade toward amputation, all clinicians who see diabetic patients should have at least a basic understanding of how to diagnose and treat this problem.
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Affiliation(s)
- Edgar J G Peters
- Department of Internal Medicine, VU University Medical Center, Room ZH4A35, PO Box 7057, Amsterdam NL-1007MB, The Netherlands.
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Baker JC, Demertzis JL, Rhodes NG, Wessell DE, Rubin DA. Diabetic musculoskeletal complications and their imaging mimics. Radiographics 2013; 32:1959-74. [PMID: 23150851 DOI: 10.1148/rg.327125054] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Diabetes mellitus is increasingly prevalent and results in various clinically important musculoskeletal disorders affecting the limbs, feet, and spine as well as in widely recognized end-organ complications such as neuropathy, nephropathy, and retinopathy. Diabetic muscle ischemia-a self-limited disorder-may be confused with infectious or inflammatory myositis, venous thrombosis, or compartment syndrome. The absence of fever and leukocytosis, combined with the presence of bilaterally distributed lesions in multiple and often noncontiguous muscles in the legs, including the thighs, is suggestive of ischemia; by contrast, the presence of well-defined intramuscular abscesses with rimlike enhancement favors a diagnosis of infectious pyomyositis. In the diabetic foot, an ulcer, sinus tract, or abscess with an adjacent region of abnormal signal intensity in bone marrow favors the diagnosis of pedal osteomyelitis over that of neuropathic arthropathy. Contrast material-enhanced magnetic resonance imaging is important when planning the treatment of foot infections in diabetic patients because it allows the differentiation of viable tissue from necrotic regions that require surgical débridement in addition to antibiotic therapy. Subtraction images are particularly useful for visualizing nonviable tissue. Dialysis-associated spondyloarthropathy characteristically occurs in diabetic patients with a long history of hemodialysis. Intervertebral disk space narrowing without T2 signal hyperintensity, extensive endplate erosions without endplate remodeling, and facet joint involvement are suggestive of spondyloarthropathy instead of infectious diskitis or degenerative disk disease. Although the clinical features of these conditions may overlap, knowledge of the patient's medical history, coupled with recognition of key imaging characteristics, allows the radiologist to make a prompt and correct diagnosis that leads to appropriate management.
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Affiliation(s)
- Jonathan C Baker
- Mallinckrodt Institute of Radiology, Musculoskeletal Section, Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110, USA.
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Howe BM, Wenger DE, Mandrekar J, Collins MS. T1-weighted MRI imaging features of pathologically proven non-pedal osteomyelitis. Acad Radiol 2013; 20:108-14. [PMID: 22981480 DOI: 10.1016/j.acra.2012.07.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Revised: 07/27/2012] [Accepted: 07/31/2012] [Indexed: 02/04/2023]
Abstract
RATIONALE AND OBJECTIVES The objective of our study was to determine if the T1-weighted magnetic resonance imaging (MRI) features associated with diabetic pedal osteomyelitis are present in histopathologically proven cases of non-pedal osteomyelitis. MATERIALS AND METHODS Seventy-five patients with a histopathologically proven diagnosis of non-pedal osteomyelitis and a preoperative MRI were identified between 2000 and 2007. The MRIs were retrospectively reviewed for signal characterization of T1-weighted images, including the signal intensity compared with skeletal muscle, distribution of abnormal signal intensity, and pattern of abnormal signal intensity. A subsequent chart review was performed to identify potential clinical factors that were more associated with atypical T1 features of osteomyelitis. Fisher's exact test was performed to determine if there was a statistically significant difference in the T1-weighted imaging features of the hematogenous and nonhematogenous mechanisms of infection. RESULTS Seventy of 75 cases demonstrated T1-weighted imaging features typical of pedal osteomyelitis with a confluent region of decreased signal intensity, hypointense, or isointense relative to skeletal muscle in a geographic pattern with medullary distribution. Of the 5 cases that did not demonstrate the typical T1 features associated with pedal osteomyelitis, 4 were considered to have a hematologic mechanism of infection given the absence of surgery, skin ulceration, or a penetrating injury. CONCLUSION The majority of cases of non-pedal osteomyelitis in our study demonstrate the typical T1-weighted imaging features previously documented to correlate with the diagnosis of pedal osteomyelitis. The cases in our series that did not demonstrate the typical T1-weighted features were predominantly secondary to a hematologic mechanism of infection.
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Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJG, Armstrong DG, Deery HG, Embil JM, Joseph WS, Karchmer AW, Pinzur MS, Senneville E. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2012; 54:e132-73. [PMID: 22619242 DOI: 10.1093/cid/cis346] [Citation(s) in RCA: 1084] [Impact Index Per Article: 90.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Foot infections are a common and serious problem in persons with diabetes. Diabetic foot infections (DFIs) typically begin in a wound, most often a neuropathic ulceration. While all wounds are colonized with microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence. Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations). This classification system, along with a vascular assessment, helps determine which patients should be hospitalized, which may require special imaging procedures or surgical interventions, and which will require amputation. Most DFIs are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common causative organisms. Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds. Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy. For infected wounds, obtain a post-debridement specimen (preferably of tissue) for aerobic and anaerobic culture. Empiric antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually require broader spectrum regimens. Imaging is helpful in most DFIs; plain radiographs may be sufficient, but magnetic resonance imaging is far more sensitive and specific. Osteomyelitis occurs in many diabetic patients with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat (often requiring surgical debridement or resection, and/or prolonged antibiotic therapy). Most DFIs require some surgical intervention, ranging from minor (debridement) to major (resection, amputation). Wounds must also be properly dressed and off-loaded of pressure, and patients need regular follow-up. An ischemic foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive measures. Employing multidisciplinary foot teams improves outcomes. Clinicians and healthcare organizations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs.
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Affiliation(s)
- Benjamin A Lipsky
- Department of Medicine, University of Washington, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA.
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FDG PET/CT imaging in the diagnosis of osteomyelitis in the diabetic foot. Eur J Nucl Med Mol Imaging 2012; 39:1545-50. [DOI: 10.1007/s00259-012-2183-z] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Accepted: 06/22/2012] [Indexed: 10/28/2022]
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Aragón-Sánchez J. Clinical–Pathological Characterization of Diabetic Foot Infections. INT J LOW EXTR WOUND 2012; 11:107-12. [DOI: 10.1177/1534734612447617] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The present study has 3 aims: ( a) to characterize the clinical and pathological features of diabetic foot infections, ( b) to show the range of clinical presentations of moderate infections, and ( c) to analyze the different behavior of diabetic foot osteomyelitis regarding to its clinical presentation. A definitive diagnosis of the type of infection was made based on intraoperative findings and histopathology. Diabetic foot infections were classified into 2 types: soft tissue and bone infections. Mild infections were always superficial. Severe infections included 75% of necrotizing soft tissue infections. Moderate infections showed ample range of clinical presentations. Eighty-one patients presented osteomyelitis. Osteomyelitis was further classified as follows: osteomyelitis without ischemia and without soft tissue involvement (class 1), osteomyelitis with ischemia without soft tissue involvement (class 2), osteomyelitis with soft tissue involvement (class 3), and osteomyelitis with ischemia and soft tissue involvement (class 4). Forty-eight patients (59.3%) with osteomyelitis underwent conservative surgery, 32 (39.5%) had minor amputations including 9 open transmetatarsal amputations, and there was 1 (1.2%) major amputation. The characterization of osteomyelitis into 4 classes showed a statistically significant trend toward increased severity and increased amputation rate and mortality. In conclusion, the clinical presentation of foot infections in diabetic patients is very heterogeneous and can be classified into soft tissue infections (cellulitis, superficial and deep abscesses, and necrotizing soft tissue infections) and osteomyelitis, which was the most frequent type of infection found in the author’s series. Their division into 4 classes showed a statistically significant trend toward increased severity, amputation rate, and mortality. The diagnosis of deep soft tissue infections associated with osteomyelitis may be difficult to achieve before surgery.
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Lipsky BA, Peters EJG, Senneville E, Berendt AR, Embil JM, Lavery LA, Urbančič-Rovan V, Jeffcoate WJ. Expert opinion on the management of infections in the diabetic foot. Diabetes Metab Res Rev 2012; 28 Suppl 1:163-78. [PMID: 22271739 DOI: 10.1002/dmrr.2248] [Citation(s) in RCA: 147] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
This update of the International Working Group on the Diabetic Foot incorporates some information from a related review of diabetic foot osteomyelitis (DFO) and a systematic review of the management of infection of the diabetic foot. The pathophysiology of these infections is now well understood, and there is a validated system for classifying the severity of infections based on their clinical findings. Diagnosing osteomyelitis remains difficult, but several recent publications have clarified the role of clinical, laboratory and imaging tests. Magnetic resonance imaging has emerged as the most accurate means of diagnosing bone infection, but bone biopsy for culture and histopathology remains the criterion standard. Determining the organisms responsible for a diabetic foot infection via culture of appropriately collected tissue specimens enables clinicians to make optimal antibiotic choices based on culture and sensitivity results. In addition to culture-directed antibiotic therapy, most infections require some surgical intervention, ranging from minor debridement to major resection, amputation or revascularization. Clinicians must also provide proper wound care to ensure healing of the wound. Various adjunctive therapies may benefit some patients, but the data supporting them are weak. If properly treated, most diabetic foot infections can be cured. Providers practising in developing countries, and their patients, face especially challenging situations.
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Affiliation(s)
- B A Lipsky
- VA Puget Sound Health Care System, University of Washington, Seattle, WA 98108, USA.
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Imaging the Diabetic Foot. Tech Orthop 2011. [DOI: 10.1097/bto.0b013e31823a0606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Demertzis JL, Rubin DA. MR imaging assessment of inflammatory, crystalline-induced, and infectious arthritides. Magn Reson Imaging Clin N Am 2011; 19:339-63. [PMID: 21665094 DOI: 10.1016/j.mric.2011.02.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The role of magnetic resonance imaging in evaluating patients with inflammatory arthritides has evolved with the recent introduction of drugs capable of modifying disease activity and natural history. In conditions like rheumatoid arthritis, active synovitis and bone marrow inflammation precede and predict bone and cartilage erosion. These imaging findings identify patients who can be treated early and aggressively to prevent future morbidity. Similarly, in gout and other crystalline disorders, specific diagnosis aided by imaging may lead to earlier medical and surgical management. Infected joints need the most rapid identification to institute immediate therapy and prevent irreversible cartilage destruction.
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Affiliation(s)
- Jennifer L Demertzis
- Division of Musculoskeletal Radiology, Mallinckrodt Institute of Radiology, 510 South Kingshighway Boulevard, Campus Box 8131, St Louis, MO 63110, USA.
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URRACA DEL JUNCO CAROLINAI, MAIR TIMS, POWELL SARAHE, MILNER PETERI, FONT ALEXF, SCHWARZ TOBIAS, WEAVER MARTINP. MAGNETIC RESONANCE IMAGING FINDINGS OF EQUINE SOLAR PENETRATION WOUNDS. Vet Radiol Ultrasound 2011; 53:71-5. [DOI: 10.1111/j.1740-8261.2011.01862.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
| | - TIM S. MAIR
- Bell Equine Veterinary Clinic; Mereworth, Maidstone; Kent; ME18 5GS; UK
| | - SARAH E. POWELL
- Rossdales Equine Hospital and Diagnostic Centre; Cotton End Road, Exning; Newmarket; Suffolk; CB8 7NN; UK
| | - PETER I. MILNER
- The Philip Leverhulme Equine Hospital; University of Liverpool; Leahurst Campus; Chester High Road; Neston; Wirral; CH64 7TE; UK
| | - ALEX F. FONT
- Bearl Equine Clinic; Bearl Farm, Bywell; Stockfield; NE43 7AS; UK
| | - TOBIAS SCHWARZ
- Royal (Dick) School of Veterinary Studies; The University of Edinburgh; Roslin; EH25 9RG; UK
| | - MARTIN P. WEAVER
- Royal (Dick) School of Veterinary Studies; The University of Edinburgh; Roslin; EH25 9RG; UK
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Seminar Review: A Review of the Basis of Surgical Treatment of Diabetic Foot Infections. INT J LOW EXTR WOUND 2011; 10:33-65. [DOI: 10.1177/1534734611400259] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Infection is an extremely challenging complication of foot ulcers in patients with diabetes. Surgery as part of a multidisciplinary approach is key in the management of many types of diabetic foot infections (DFIs). Unfortunately, the surgical treatment of DFIs is based more on clinical judgment and less on structured evidence, which leaves unresolved doubts. The clinical presentation of DFIs is varied. This review examines the basis of nonvascular surgical treatment of DFIs, emphasizing the importance of the anatomic concepts of the foot, the variety of its clinical presentations, and the concepts of timing surgery. Recent evidence and case reports based on the author’s experience are presented in 2 parts. The first part examines clinical presentation of infections, whereas the second part deals with imaging, foot anatomy, and some case reports.
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Donovan A, Schweitzer ME. Use of MR imaging in diagnosing diabetes-related pedal osteomyelitis. Radiographics 2010; 30:723-36. [PMID: 20462990 DOI: 10.1148/rg.303095111] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The clinical diagnosis of diabetes-related osteomyelitis relies on the identification and characterization of an associated foot ulcer, a method that is often unreliable. Magnetic resonance (MR) imaging is the modality of choice for imaging evaluation of pedal osteomyelitis. Because MR imaging allows the extent of osseous and soft-tissue infection to be mapped preoperatively, its use may limit the extent of resection. At MR imaging, the simplest method to determine whether osteomyelitis is present is to follow the path of an ulcer or sinus tract to the bone and evaluate the signal intensity of the bone marrow. Combined findings of low signal intensity in marrow on T1-weighted images, high signal intensity in marrow on T2-weighted images, and marrow enhancement after the administration of contrast material are indicative of osteomyelitis. Secondary signs of osteomyelitis include periosteal reaction, a subtending skin ulcer, sinus tract, cellulitis, abscess, and a foreign body. The location of a marrow abnormality is a key distinguishing feature of osteomyelitis: Whereas neuroarthropathy most commonly affects the tarsometatarsal and metatarsophalangeal joints, osteomyelitis occurs distal to the tarsometatarsal joint, in the calcaneus and malleoli. In the midfoot, secondary signs of infection help differentiate between neuroarthropathy and a superimposed infection.
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Affiliation(s)
- Andrea Donovan
- Department of Radiology, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Room AG 278, Toronto, Ontario, Canada M4N 3M5.
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Boado A, Kristoffersen M, Dyson S, Murray R. Use of nuclear scintigraphy and magnetic resonance imaging to diagnose chronic penetrating wounds in the equine foot. EQUINE VET EDUC 2010. [DOI: 10.1111/j.2042-3292.2005.tb00338.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Diagnostic performance of FDG-PET, MRI, and plain film radiography (PFR) for the diagnosis of osteomyelitis in the diabetic foot. Mol Imaging Biol 2009; 12:335-42. [PMID: 19816744 DOI: 10.1007/s11307-009-0268-2] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2009] [Revised: 05/11/2009] [Accepted: 05/29/2009] [Indexed: 12/14/2022]
Abstract
BACKGROUND The early and accurate diagnosis of osteomyelitis in the diabetic foot is essential to provide appropriate treatment and obviate long-term complications of the disease. The currently employed non-invasive imaging modalities such as plain film radiography (PFR) lack the sensitivity to accurately exclude osteomyelitis, while magnetic resonance imaging (MRI) is limited by its low specificity and contraindications in certain patients. Therefore, accurate non-invasive detection of osteomyelitis in the diabetic foot remains a challenge. [18F]-2-fluoro-2-deoxy-D-glucose (FDG)-positron emission tomography (PET) has been proven useful in other settings to detect infection. In this ongoing prospective study, we assessed the diagnostic performance of FDG-PET to diagnose osteomyelitis in the diabetic foot and compared it with that of MRI and PFR. METHODS Patients who met the prespecified criteria for complicated diabetic foot underwent FDG-PET, MRI, and PFR of the feet. Each imaging study was then interpreted in a blinded fashion for presence of osteomyelitis or other abnormalities. The gold standard for diagnosis in each patient was based on surgical, microbiological, and clinical follow-up results. RESULTS One hundred ten consecutive patients have been enrolled to date into this prospective project. FDG-PET correctly diagnosed osteomyelitis in 21 of 26 patients and correctly excluded it in 74 of 80, with sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of 81%, 93%, 78%, 94%, and 90%, respectively. MRI correctly diagnosed osteomyelitis in 20 of 22 and correctly excluded it in 56 of 72, with sensitivity, specificity, PPV, NPV, and accuracy of 91%, 78%, 56%, 97%, and 81%, respectively. PFR correctly diagnosed osteomyelitis in 15 of 24 and correctly excluded it in 65 of 75, with sensitivity, specificity, PPV, NPV, and accuracy of 63%, 87%, 60%, 88%, and 81%, respectively. CONCLUSION FDG-PET is a highly specific imaging modality for the diagnosis of osteomyelitis in diabetic foot and, therefore, should be considered to be a useful complimentary imaging modality with MRI. In the setting where MRI is contraindicated, the high sensitivity and specificity of FDG-PET justifies its use after a negative or inconclusive PFR to aid an accurate diagnosis.
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Abstract
Diabetic pedal osteomyelitis is primarily a manifestation of vascular insufficiency with resultant tissue ischemia, neuropathy, and infection. Nearly all cases of pedal osteomyelitis arise from a contiguous ulcer and soft tissue infection. MR imaging is the modality of choice to assess for the presence of osteomyelitis and associated soft tissue complications, to guide patient management, and to aid in limited limb resection.
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Abstract
MR imaging can be quite useful in the evaluation of pathologic processes related to the diabetic foot. The diagnosis of soft tissue processes such as callus formation, ulceration, foreign body granuloma, cellulitis, abscess, and gangrene can be made with the assistance of MR imaging. Osseous deformities such as hammertoe, rocker-bottom foot, neuropathic osteoarthropathy, and osteomyelitis can be detected and defined with MR imaging. Finally, although there are some overlapping features of neuropathic osteoarthropathy and osteomyelitis, the differentiation between the two entities is possible in most instances with the aid of MR imaging.
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