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Osteomyelitis:
Osteomyelitis in a diabetic with neuropathy is infection of the bone that usually results from
contiguous spread of a skin ulcer.
Consequently, the most common location for osteomyelitis is not in the midfoot, but at the
pressure points of the forefoot (metatarsal heads, IP joints) and in the hindfoot at the plantar
aspect of the posterior calcaneus.
To determine whether osteomyelitis is present, place a marker on the ulcer or sinus tract and
track it down to the bone and evaluate the MR- signal intensity of the marrow (1).
Active Charcot:
Unlike osteomyelitis, Charcot neuro-osteoarthropathy is primarily an articular disease, which
is most commonly located in the midfoot.
In the early stage radiography will not demonstrate bone abnormalities, but MRI will show
subchondral bone marrow edema.
The subcutaneous soft tissues are not typically involved.
Signal intensities on MRI will not discriminate between active Charcot Joint and
osteomyelitis.
Location, i.e. bone or joint and ulcer or not, are the clues to the right diagnosis.
Osteomyelitis
The probe-to-bone test, i.e. palpation of bone with a sterile blunt metal probe in the depths of
infected pedal ulcers was thought to be highly correlated with ostemyelitis.
In later studies, however, it had a relatively low positive predictive value (7).
On plain radiographs, bone infection may not show up on the first 2 weeks and in a later
stage the radiographic characteristics of neuro-osteoarthropathy and osteomyelitis overlap.
In both cases there will be demineralization, destruction and periosteal reaction of the bones,
particularly when neuro-osteoarthropathy presents at a later stage.
Here, images of a patient with a small cutaneous defect and subcutaneous edema at the
metatarsals.
A secondary sign, an abscess, is shown in the forefoot, with high signal intensity on STIR,
low or intermediate signal on intensity T1W, and ring-enhancement of the borders showing
high signal intensity on T1+Gd.
Charcot neuro-osteoarthropathy
The neurovascular theory suggests that the underlying condition leads to the development of
autonomic neuropathy, causing the extremity to receive an increased blood flow, which in
turn results in a mismatch in bone destruction by increased osteoclastic activity and bone
synthesis (1).
Acute Charcot
Here a radiograph of a patient with diabetic neuropathy and a red hot foot.
In the acute stage, the radiographs are normal and may not exclude the diagnosis of acute
Charcot neuro-osteoarthropathy.
Within 4 months there is progressive decrease of calcaneal inclination with equinus deformity
at the ankle.
There is destruction of the tarsometatarsal joint with the typical rocker-bottom deformity.
In the acute stage, MRI shows only subchondral bone marrow edema.
Chronic Charcot
The chronic inactive stage no longer shows a warm and red foot.
The edema usually persists.
Crepitus, palpable loose bodies and large osteophytes are the result of extensive bone and
cartilage destruction.
Joint deformity, subluxation and dislocation of the metatarsals lead to a rocker-bottom type
deformity in which the cuboid becomes a weight-bearing structure.
This results in excessive skin callus formation, blisters and foot ulceration.
At the stage of chronic inactive Charcot osteoarthropathy, bone healing and change of active
periosteal reaction will proceed into inactive periosteal reaction and sclerotic borders.
To determine whether osteomyelitis in a Charcot foot at MR imaging is present, follow the
path of an ulcer or sinus tract to the bone and evaluate the signal intensity of the bone
marrow.
If there is bone marrow edema, osteomyelitis is very likely.
If there is bone marrow edema in the absence of a cutaneous defect, active Charcot may be
present.
If it is normal, both active Charcot as well as osteomyelitis is not likely.
Charcot foot with rocker-bottom deformity and ulceration beneath the bony protuberance of
the cuboid
On the left a typical rocker-bottom deformity of the foot due to collapse of the longitudinal
arch.
Abnormal pressure on the cuboid has led to ulceration.
STIR and T1W images in Charcot neuro-osteoarthropathy with a plantar ulcer (asterix) and
osteomyelitis of the cuboid.
In a patient with Charcot neuro-osteoarthropathy and a rocker-bottom foot, the cuboid bone is
an important location of osteomyelitis.
If the T1-weighted image at that location shows low signal intensity in combination with a
cutaneous defect, osteomyelitis is extremely likely.
On the left STIR and T1-weighted images of a patient with active Charcot neuro-
osteoarthropathy with a plantar ulcer along the bony protuberance of the cuboid.
There is abnormal signal intensity in the cuboid bone next to the ulcer, indicative of
osteomyelitis.
Here the contrast enhanced images with and without fat saturation.
Enhancement of the cuboid bone and adjacent soft tissues on postcontrast images, together
with the plantar ulcer, makes osteomyelitis very likely.
On the left a patient with Charcot neuro-osteoarthropathy with a subcutaneous fistula tract
(arrow).
This patient has subcutaneous edema and swelling.
When we follow the fistula tract to the bony protuberances of the cuboid, there is no marrow
edema at the midfoot.
This makes yet osteomyelitis unlikely.
Ghost sign
The ghost sign is indicative of neuro-osteoarthropathy with superimposed osteomyelitis.
The "ghost sign" refers to poor definition of the margins of a bone on T1-weighted images,
which become clear after contrast administration.
Here, a patient with neuro-osteoarthropathy and superimposed osteomyelitis.
The areas of osteomyelitis are more pronounced on the contrast-enhanced T1-weighted image
as compared to the native T1-weighted image.
The bone marrow edema, which is of low signal intensity on the T1-weighted image without
contrast enhances and becomes as bright as normal bone marrow.
MRI protocol
The MRI examination includes special attention for positioning of the foot. It must be placed
in the center of the magnet, to obtain homogeneous fat suppression.
Markers have to be placed over ulcers or sinus tracts.
T1 and STIR or T2 fatsat sequences are needed.
Because of the curvature of the foot, fat suppression is more uniform with the use of STIR
than with T2- weighted imaging with chemical fat saturation.
However, STIR cannot be combined with contrast administration.
As an alternative to spectral fat saturation technique, Dixon chemical shift imaging is
described (8).
Sagittal views are for evaluation of midfoot involvement, the plantar surface and the posterior
calcaneus.
A view parallel to the toes is adequate for imaging the metatarsophalangeal and
interphalangeal joints.
Contrast is used to better depict devitalized regions, abscesses, sinus tracts and joint or tendon
involvement.
by Byron M Perrin et al
Australian Family Physician Vol.39 no.3 march2010
By Robert Bem et al
Diabetes Care, Volume 29, number 6, june 2006
Benjamin Lipsky et al
Clin Infect Dis. 2004, 39 (7): 885-910
by Lawrence A. Lavery et al
Diabetes Care February 2007 vol. 30 no. 2 270-274
8. Uniform fat suppression in hands and feet through the use of two-point Dixon
chemical shift MR imaging.