MRI of the cuboid bone: analysis of changes in diabetic versus non-diabetic patients and their clinical significance

Outcomes of open or closed treatment of foot fractures: A database study comparing patients with and without diabetes

Treatment of ankle and foot fractures in patients with diabetes mellitus (DM) is challenging, and complications may arise. Although much data exists on complication rates in tibial, fibular, and malleolar fractures, there exists a comparable lack of data on complication rates in fractures of the tarsal, metatarsal, and phalanx bones of the foot. Therefore, we aimed to compare post-procedural outcomes after such fractures in diabetic vs non-diabetic patients. A commercially available de-identified database was searched using ICD-10 codes for the open or closed surgical treatment in patients with fractures of the calcaneus, cuboid, navicular, talus, cuneiforms, metatarsals, and phalanges from 2010 to 2023. Patients with at least 1 year of post-procedural follow-up were included. We then separated patients into two groups: those with diabetes (108,603, 26.4 %) and those without diabetes (302,464, 73.6 %). Post-procedural complications assessed including those related to hardware when surgical treatment was pursued (reoperation, non-union, malunion, delayed union, wound disruption, surgical site infection) and health complications after fracture treatment (AKI, DVT, MI, pneumonia, sepsis) were assessed at 1 year and odds ratios were used to compare rates of these complications in diabetics vs non-diabetics for each bone. Rates of complications after fracture treatment were found to be significantly higher in all bones for diabetic patients compared to non-diabetic patients.

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

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

Preliminary evaluation of dual-energy CT to quantitatively assess bone marrow edema in patients with diabetic foot ulcers and suspected osteomyelitis

OBJECTIVES

The purpose of this study is to evaluate the value of dual-energy CT (DECT) with virtual non-calcium (VNCa) in quantitatively assessing the presence of bone marrow edema (BME) in patients with diabetic foot ulcers and suspected osteomyelitis.

METHODS

Patients with a diabetic foot ulcer and suspected osteomyelitis that underwent DECT (80 kVp/Sn150 kVp) with VNCa were retrospectively included. Two observers independently measured CT values of the bone adjacent to the ulcer and a reference bone not related to the ulcer. The patients were divided into two clinical groups, osteomyelitis or no-osteomyelitis, based on the final diagnosis by the treating physicians.

RESULTS

A total of 56 foot ulcers were identified of which 23 were included in the osteomyelitis group. The mean CT value at the ulcer location was significantly higher in the osteomyelitis group (- 17.23 ± 34.96 HU) compared to the no-osteomyelitis group (- 69.34 ± 49.40 HU; p < 0.001). Within the osteomyelitis group, the difference between affected bone and reference bone was statistically significant (p < 0.001), which was not the case in the group without osteomyelitis (p = 0.052). The observer agreement was good for affected bone measurements (ICC = 0.858) and moderate for reference bone measurements (ICC = 0.675). With a cut-off value of - 40.1 HU, sensitivity was 87.0%, specificity was 72.7%, PPV was 69.0%, and NPV was 88.9%.

CONCLUSION

DECT with VNCa has a potential value for quantitatively assessing the presence of BME in patients with diabetic foot ulcers and suspected osteomyelitis.

KEY POINTS

• Dual-energy CT (DECT) with virtual non-calcium (VNCa) is promising for detecting bone marrow edema in the case of diabetic foot ulcers with suspected osteomyelitis. • DECT with VNCa has the potential to become a more practical alternative to MRI in assessing the presence of bone marrow edema in suspected osteomyelitis when radiographs are not sufficient to form a diagnosis.

ACR Appropriateness Criteria® Chronic Foot Pain

Chronic foot pain is a frequent clinical complaint, which can significantly impact the quality of live in some individuals. These guidelines define best practices with regards to requisition of imaging studies based on specific clinical scenarios, which have been grouped into different variants. Each variant is accompanied by a brief description of the usefulness, advantages, and limitations of different imaging modalities. The present narrative is the result of an exhaustive assessment of the available literature and a thorough review process by a panel of experts on Musculoskeletal Imaging. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

MR imaging features of cuboid fractures in children

BACKGROUND

Cuboid fractures are rare, usually occult on initial radiographs and are often underdiagnosed. MRI is more sensitive than radiographs for detecting acute, non-displaced cuboid fractures in adults, but only case reports have described these findings in children.

OBJECTIVE

To summarize the MR and clinical features of cuboid fractures and compare MR findings with initial and follow-up radiographs in a cohort of children.

MATERIALS AND METHODS

A retrospective search for patients <18 years of age with cuboid fractures was performed during a 10-year period at a large tertiary children's hospital. Subjects with cuboid fractures reported on MRI and available clinical history were included. MR images were evaluated for fracture location, fracture morphology, percentage of marrow edema in the cuboid, subchondral disruption, and associated tendon or ligamentous injury. Initial and short-term follow-up radiographs were also reviewed when available.

RESULTS

Nineteen children ages 18 months to 17 years (mean: 9.0 years, standard deviation: 4.1 years, 63% boys) were diagnosed with cuboid fractures by MRI. Most cases of cuboid fractures are related to acute trauma (63%) but can be seen as stress fractures (16%). Most fractures (17/19, 89%) were linear in configuration. Fractures were most commonly adjacent to the tarsometatarsal joint (10/19, 52%). The degree of marrow edema was variable. Ligamentous injury was seen in two patients and tendon pathology was seen in one, all adolescents. Initial radiographs (n=10) were negative in 9 cases (90%). All available follow-up radiographs (n=12, obtained 19-42 days after MRI) demonstrated sclerosis in the region of the fracture.

CONCLUSION

MR-depicted cuboid fractures in children typically occur in isolation. The fractures were most commonly adjacent to the tarsometatarsal joint and linear in morphology. Initial radiographs were usually normal and follow-up radiographs depicted sclerosis at the site of fracture in all available cases.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Lower limb complications of diabetes mellitus: a comprehensive review with clinicopathological insights from a dedicated high-risk diabetic foot multidisciplinary team

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.