Neuropathic osteoarthropathy with and without superimposed osteomyelitis in patients with a diabetic foot

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.

Comparison of White Blood Cell Scintigraphy, FDG PET/CT and MRI in Suspected Diabetic Foot Infection: Results of a Large Retrospective Multicenter Study

“…However, lower limb ischemia is a common diagnostic problem that also affects the correct interpretation of WBC scintigraphy, especially for the detection of STI, since a reduced vascular supply could impair leukocytes’ recruitment into infected sites [ 29 ]. Moreover, in the diabetic foot, the possible presence of Charcot and mechanical stress can be responsible for changes in the bone marrow or soft tissue intensity that could be erroneously interpreted as an OM, thus impairing the specificity of MRI [ 40 , 41 , 42 ].…”

Multivariate analyses of MRI findings for predicting osteomyelitis of the foot in diabetic patients

“…Although Leone et al. (26) demonstrated that diffuse bone marrow involvement, ghost sign, replacement of soft tissue fat, sinus tract formation, progressive bony erosions, disappearance of subchondral cysts or intra-articular bodies, and diffuse joint fluid enhancement were more common in infected neuropathic osteoarthropathy than neuropathic osteoarthropathy without osteomyelitis, differentiation between them is challenging. To overcome these problems, we only included cases located on the forefoot, metatarsal head, calcaneus, and lateral malleolus, which are the most frequently involved anatomical sites of osteomyelitis in patients with diabetic foot (11,24).…”

Molecular Imaging of Diabetic Foot Infections: New Tools for Old Questions

“…Studies published in the last two decades have described the variable performance of 18 F-FDG PET in the assessment of DFI with a wide range of sensitivity and specificity [57,60]. Differences in patient populations, co-existing conditions such as hyperglycemia and peripheral artery diseases (PAD), and antibiotic usage make direct comparisons between multiple studies challenging [61,62]. While some preliminary studies suggest that hyperglycemia does not affect the diagnostic performance of 18 F-FDG, further validation is still required [63,64].…”