Magnetic Resonance Imaging for Diagnosing Foot Osteomyelitis
Discussion in 'Diabetic Foot & Wound Management' started by NewsBot, Jan 24, 2007.
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Magnetic Resonance Imaging for Diagnosing Foot Osteomyelitis: A Meta-analysis.
Arch Intern Med. 2007 Jan 22;167(2):125-32
Kapoor A, Page S, Lavalley M, Gale DR, Felson DT
BACKGROUND: Uncertainty exists regarding the optimal workup of patients with suspected osteomyelitis of the foot, many of whom have diabetes mellitus. We conducted a meta-analysis to determine the diagnostic test performance of magnetic resonance imaging (MRI) for osteomyelitis of the foot and compared this performance with that of technetium Tc 99m bone scanning, plain radiography, and white blood cell studies.
METHODS: We searched MEDLINE (from 1966 to week 3 of June 2006) and EMBASE (from 1980 to week 3 of June 2006) for English-language studies in which adults suspected of having osteomyelitis of the foot or ankle were evaluated by MRI. We then extracted data using a standard form derived from the Cochrane Methods Group. To summarize the performance of diagnostic tests, we used the summary receiver operating characteristic curve analysis, which relies on the calculation of the diagnostic odds ratio (DOR). We also examined subsets of studies defined by the presence or absence of particular design flaws or populations.
RESULTS: Sixteen studies met inclusion criteria. In all studies combined, the DOR for MRI was 42.1 (95% confidence interval, 14.8-119.9), and the specificity at a 90% sensitivity cut point was 82.5%. The DOR did not vary greatly among subsets of studies. In studies in which a direct comparison could be made with other technologies, the DOR for MRI was consistently better than that for bone scanning (7 studies-149.9 vs 3.6), plain radiography (9 studies-81.5 vs 3.3), and white blood cell studies (3 studies-120.3 vs 3.4).
CONCLUSIONS: We found that MRI performs well in the diagnosis of osteomyelitis of the foot and ankle and can be used to rule in or rule out the diagnosis. Magnetic resonance imaging performance was markedly superior to that of technetium Tc 99m bone scanning, plain radiography, and white blood cell studies.
Osteomyelitis in the diabetic foot
Foot ulcer and osteomyelitis case
Admin2, Jan 24, 2007
rajna Member
This is great - but have you tried getting access to an mri? I work in a public hospital and inpatients have been discharged simply to access mri's as the current system pays more for outpatient access. In addition there is quite a waiting period to access the machine. There needs to be some way of being able to increase speed of access to patients with suspected osteomyelitis so that diagnosis can occur quickly and treatment implemented in a timely manner. Any ideas?
rajna, Feb 6, 2007
Role of magnetic resonance imaging in the evaluation of diabetic foot with suspected osteomyelitis.
Rozzanigo U, Tagliani A, Vittorini E, Pacchioni R, Brivio LR, Caudana R.
Radiol Med. 2008 Oct 25. [Epub ahead of print]
PURPOSE: This study evaluated Magnetic Resonance Imaging (MRI) in infected diabetic foot ulcers.
MATERIALS AND METHODS: Sixteen diabetic patients underwent foot MRI between January 2006 and September 2007 for suspected unilateral osteomyelitis. Three of 16 patients showed radiographic changes due to Charcot neuropathic osteoarthropathy. Twelve of 16 patients also underwent MR angiography of the lower limbs for the purpose of planning surgical or endovascular treatment. The musculoskeletal and vascular MRI studies were retrospectively reviewed by three radiologists.
RESULTS: The final diagnosis, based on clinical, imaging, microbiological and histological findings, was osteomyelitis in 13/16 cases. Foot MRI allowed a correct diagnosis in 15/16 patients, with 1 false positive result demonstrated by computed tomography (CT)-guided bone biopsy. MR angiography of the lower limbs was considered nondiagnostic in 5/12 patients in the infrapopliteal region owing to venous contamination.
CONCLUSIONS: MRI has high sensitivity for the detection of osteomyelitis in the diabetic foot but lower specificity related to Charcot neuropathic osteoarthropathy. If diagnostic uncertainty persists, a bone biopsy is indicated. The inflammatory hyperaemia caused by the ulcer deteriorates the diagnostic quality of 40%-50% of MR angiography studies in the infrapopliteal region. In these cases, selective arteriography is appropriate, as it can be performed in the same session as angioplasty.
Greg Fyfe Active Member
Interesting and relavant thread.
I recently encountered a 35 yr old client , with diabetes,who was admitted to hospital 8 weeks ago and given i.v. antibiotics for an wound beneath the 1st ip joint.
Unclear weather she was discharged with oral cover, certainly currently is not on any.
. X rays have been taken twice and not demonstrated signs of osteomyelitis.
I debrided the wound recently it had some hypergranulation tissue, modest exudate and nil odour. The toe is swollen apprx 2x normal size and the client denies any symptoms of systemic illness. The foot has good circulation and the HbA1c is over 12.
In discussion with the visiting Dr ,he declined to prescribe any antibiotics but review the case in a couple of weeks. Logic being that as the wound had been reported as improving (therefore antibiotics were not nessecary) then if it was not progressing on next review an mri was nessecary before surgical debridement of the bone could be undertaken.
As rjna points out the issues in accessing mri in a timely manner are significant, and perhaps there is a case for management on the basis of "clinical suspicion"
Furthermore i feel the Dr's course of management is inappropriate or is it just me?
I'd be interested in your views.
Greg Fyfe, Dec 17, 2008
drsarbes Well-Known Member
"This is great - but have you tried getting access to an mri?"
hmmmmmmmmmmm
I wish EVERYONE on the US of A could read this post. especially those who THINK they WANT National Health Care!!!
Even in my smallish town of 100,000 we have several MRI centers having to MARKET themselves for utilization. In fact, if you so much as twist your knee you'll end up with an MRI.
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
drsarbes, Dec 17, 2008
Ryan McCallum Active Member
any further details on this case? Is the patient neuropathic? How longstanding is this ulceration? When were the x-rays taken? Other than her IV antibiotics, what other care has she received for this problem? Has there been input from any other departments? Has the patient had any recent blood tests?
With a HbA1c of 12, I am not surprised this patient is still requiring care. Is her diabetes normally this poorly controlled? This needs to be sorted out ASAP.
Where I work, we are quite lucky with the resources available to us but if we are caring for a patient on an inpatient basis, we routinely run CRP, FBC and take regular swabs. Relying on wound inspection and x-rays doesn't really provide enough information for me. We do not routinely request MR scans for cases suspicious of osteomyelitis (the orthopods on the other hand tend to request them all the time).
I would be suspicious of osteomyelitis in this case you have described. Whether the Dr's management is inappropriate would depend on the bigger picture but I think your "clinical suspicion" counts for an awful lot!
Look forward to hearing a few more details about this case,
Ryan McCallum, Dec 17, 2008
Hi Ryan
No the patient is not neuropathic.
Her diabetes is generally poorly controlled as she is not reliable about taking her medication.
Im not sure how old the ulcer is as she first presented 8 weeks ago ( not to me) and at that stage the notes record that she was systemically unwell and maggots were present in the wound. It's probably 1.5-2 cm diameter and I cannot probe to bone.
The x rays were close to the time of admission and 1 month later.
The patient comes from a remote area that has resident nursing staff available and a visiting Dr about once a week it is some 6hrs drive to the nearest small town hospital.
Im now wondering if she would be better managed in hospital as her bsl could be stabilised which I think would assist with wound management, although I guess that the admission criteria may require her to be more unwell.
Conservative management of diabetic forefoot ulceration complicated by underlying osteomyelitis: the benefits of magnetic resonance imaging.
Valabhji J, Oliver N, Samarasinghe D, Mali T, Gibbs RG, Gedroyc WM.
Diabet Med. 2009 Nov;26(11):1127-34.
Aims To assess efficacy of conservative management of neuropathic forefoot ulcers with underlying osteomyelitis in subjects with diabetes when magnetic resonance imaging (MRI) is used to confirm or establish diagnosis and to guide antibiotic duration.
Methods A retrospective cohort study over 6 years assessing rates of ulcer healing, relapse and amputation. Antibiotics were continued for 3-month cycles with interval MRI: if the lesion had healed and bone signal change resolved or improved, antibiotics were discontinued; if the lesion had not healed or there was no difference in bone signal change, antibiotics were continued for a further 3-month cycle; clinical or radiological deterioration resulted in endoluminal or open vascular surgical intervention where appropriate, or digital or more proximal amputation.
Results There were 53 episodes in 47 subjects (mean +/- sd age 62 +/- 13 years, duration of diabetes 19 +/- 13 years, glycated haemoglobin 8.4 +/- 1.6%; six with Type 1 diabetes and seven with end-stage renal failure). Successful healing without relapse was achieved in 40 episodes (75%) [median (range) duration of antibiotics 6 (3-12) months and follow-up post-cessation of antibiotics 15 (3-58) months]. Relapse occurred in six episodes (13%) at 31 (2-38) months post-cessation of antibiotics. There were one major (2%) and eight minor (15%) amputations. Five subjects have died (11%), all without foot ulcers.
Conclusions High rates of healing and low rates of amputation were achieved. The use of MRI was associated with long courses of antibiotics, but particularly low relapse rate
Efficacy of Magnetic Resonance Imaging in Diagnosing Osteomyelitis in Diabetic Foot Ulcers
Miki Fujii, Hiroto Terashi and Shinya Tahara
J Am Podiatr Med Assoc 104(1): 24–29, 2014
Background: The clinical diagnosis of osteomyelitis is difficult because of neuropathy, vascular disease, and immunodeficiency; also, with no established consensus on the diagnosis of foot osteomyelitis, the reported efficacy of magnetic resonance imaging (MRI) in detecting osteomyelitis and distinguishing it from reactive bone marrow edema is unclear. Herein, we describe a retrospective study on the efficacy of MRI for decision-making accuracy in diagnosing osteomyelitis in diabetic foot ulcers.
Methods: Twelve diabetic patients with infected foot ulcers underwent preoperative MRI between January 1, 2008, and December 31, 2011. The findings were compared with the histopathologic features of 67 parts of 45 resected bones, the cut ends of which were also histopathologically evaluated.
Results: Osteomyelitis was disclosed by MRI and histopathologically confirmed in 30 parts. In contrast, bone marrow edema diagnosed by MRI in 29 parts was confirmed in 23; the other six parts displayed osteomyelitis. Among 17 resected bones, 13 cut ends displayed bone marrow edema and four were normal. All of the wounds healed uneventfully.
Conclusions: In the diagnosis of diabetic foot ulcers, osteomyelitis is often reliably distinguished from reactive bone marrow edema, except in special cases.
Abbreviated MRI of the foot in patients with suspected osteomyelitis.
Kotecha HM et al
Emerg Radiol. 2019 Aug 28
To determine the diagnostic accuracy of an abbreviated magnetic resonance imaging (MRI) protocol of the foot for the diagnosis of osteomyelitis in patients with acute foot infection.
This retrospective study evaluated adult patients (age 18 and over) visiting an academic medical center from 1 January 2013 to 31 December 2015 who were imaged with MRI for suspected acute pedal osteomyelitis. Examinations were performed utilizing the departmental standard protocol. All examinations were retrospectively interpreted by five radiologists under two protocols: a reference standard protocol consisting of all non-contrast sequences obtained at initial acquisition and an abbreviated protocol consisting of only coronal T1-weighted and sagittal T2-weighted fast multiplanar inversion-recovery (FMPIR) sequences. Interpretation of the two imaging subsets was separated in time by at least 6 weeks for each reader. Each examination was assigned a score to represent one of four diagnostic categories: normal; soft tissue infection without bone changes or bone changes specific to a non-infectious etiology; nonspecific bone marrow changes; or bone changes specific for osteomyelitis. Diagnostic accuracy of both protocols was determined based on clinical diagnosis and treatment of osteomyelitis, and histopathology when available.
One hundred and two MRI examinations met inclusion criteria; participants ranged in age from 26 to 91 years, with a mean age of 59 years. Seventy examinations were performed for male participants (69%) and 32 for female participants (31%). Thirty-five had a confirmed diagnosis of osteomyelitis, while the remainder (n = 67) did not. An average of 6 non-contrast sequences was performed during each examination. The most common protocol (53/102 examinations) was comprised of the following 6 sequences: axial T1-weighted, axial fat-saturated proton density, sagittal T1-weighted, sagittal T2-weighted FMPIR, coronal T1-weighted, and coronal fat-saturated proton density. After patient positioning, the abbreviated protocol sequences (sagittal T2-weighted FMPIR and coronal T1-weighted) were performed in an average total of 8 min. The reference standard protocol required an average of 22 min to complete 6 sequences. Averaged across all readers, the AUC for the reference standard full protocol and the abbreviated protocols were 0.843 and 0.873, respectively. The difference in AUC between protocols was not statistically significant (p = 0.1297), with the abbreviated protocol showing a non-significantly greater AUC.
An abbreviated MRI protocol, including only coronal T1-weighted and sagittal T2-weighted FMPIR images, is non-inferior to standard MRI protocol for the diagnosis of acute pedal osteomyelitis. It should be considered as a diagnostic alternative for reducing imaging time and improving patient access to MRI.
NewsBot, Sep 1, 2019
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