Imaging of the Diabetic Foot.

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.

Prevalence of Vertebral Fractures and Their Prognostic Significance in the Survival in Patients with Chronic Kidney Disease Stages 3‒5 Not on Dialysis.

Background: The prevalence of vertebral fractures (VF) and their association with clinical risk factors and outcomes are poorly documented in chronic kidney disease (CKD) cohorts. The aim of the study was to evaluate the prevalence of VF in patients with non-dialysis dependent CKD (NDD-CKD), their value in predicting mortality and its correlation with parameters of bone mineral metabolism and vascular calcification. Materials and Methods: 612 NDD 3‒5 stage CKD patients participating in the OSERCE-2 study, a prospective, multicenter, cohort study, were prospectively evaluated and categorized into two groups according to presence or absence of VF at enrollment. VF were assessed with lateral radiographs and Genant semi-quantitative method was applied. Three radiologists specialized in musculoskeletal radiology performed consensual reading of individual images obtained using a Raim DICOM Viewer and a Canon EOS 350 camera to measure with Java Image software in those who had traditional acetate X-ray. Factors related to VF were assessed by logistic regression analysis. Association between VF and death over a 3-year follow-up was assessed by Kaplan-Meier survival curves and Cox-proportional hazard models. Results: VF were detected in 110 patients (18%). Serum phosphate levels (OR 0.719, 95% CI 0.532 to 0.972, p = 0.032), ankle-brachial index < 0.9 (OR 1.694, 95% CI 1.056‒2.717, p = 0.029) and treatment with bisphosphonates (OR 5.636, 95% CI 1.876‒16.930, p = 0.002) were independently related to the presence of VF. After a median follow-up of 35 months (IQR: 17‒37 months), 62 patients (10%) died. The causes of death were cardiovascular (n = 21, 34%) and infectious (n = 11, 18%). In the crude analysis, fractured patients group had poorer survival (log-rank test, p = 0.02). After multivariate adjustment for age, MDRD, albumin, diabetes mellitus, comorbidity, Adragao Score > 3 and serum phosphate, the presence of VF (HR 1.983, 95% CI 1.009‒3.898, p = 0.047) were an independent predictor of all-cause mortality. Conclusions: In our study 18% of patients with NDD-CKD have VF. Factors associated with VF were age, low serum phosphate levels and peripheral vascular disease. The presence of VF was an independent risk factor for mortality in stages 3‒5 NDD-CKD patients. Clinical trials are needed to confirm whether this relationship is causal and reversible with treatment for osteoporosis.

Value of multidetector computed tomography for the differentiation of delayed aseptic and septic complications after total hip arthroplasty.

OBJECTIVE: The differentiation between delayed aseptic and septic complications of total hip arthroplasty is crucial to allow appropriate surgical planning and timely antimicrobial treatment. The aim of this study was to investigate the utility of multidetector computed tomography (CT) findings to diagnose aseptic mechanical loosening, granulomatous reaction, and periprosthetic joint infection in patients who underwent total hip arthroplasty before revision surgery. MATERIALS AND METHODS: Ninety-six consecutive patients with a clinical suspicion of periprosthetic complications underwent revision surgery over an 8-year period. All patients had been evaluated preoperatively using multidetector CT without contrast media. Two blinded musculoskeletal radiologists reviewed multidetector CT images, including periprosthetic soft-tissue accumulation, prosthetic acetabular malposition, periprosthetic osteolysis, enlarged iliac lymph nodes, and heterotopic ossification. Risk factors for aseptic and septic loosening were identified using multivariate analysis. RESULTS: Multidetector CT-related variables independently associated with periprosthetic joint infection were high periprosthetic soft-tissue accumulation, periprosthetic osteolysis without expansile periosteal reaction and enlarged iliac lymph nodes. On the other hand, the absence of the following radiological signs: low or high periprosthetic soft-tissue accumulation, mild or severe periprosthetic osteolysis, and enlarged iliac lymph nodes, were predictors of aseptic mechanical loosening. Low periprosthetic soft-tissue accumulation, severe periprosthetic osteolysis with expansile periosteal reaction, and mild acetabular malposition were significant variables associated with granulomatosis. CONCLUSION: Multidetector CT findings are useful to differentiate between aseptic and septic complications before revision surgery. The presence of osteolysis with expansile periosteal reaction appeared to be a time-dependent variable.

Hallazgos radiográficos de cuerpos extraños metálicos secundarios a acupuntura permanente / Radiographic findings of metallic foreign bodies due to permanently retained acupuncture needles

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Accuracy of Computed Tomography-Guided Joint Aspiration and Computed Tomography Findings for Prediction of Infected Hip Prosthesis.

BACKGROUND: Infection after total hip arthroplasty remains a diagnostic challenge. We assessed the accuracy of computed tomography (CT)-guided joint aspiration combined with CT findings for prediction of septic hip prosthesis before revision surgery. METHODS: A total of 96 patients (64.6% men; mean age, 68 years) scheduled for elective revision surgery due to suspicion of infection after total hip arthroplasty underwent CT-guided joint aspiration. Volume and microbiological cultures of aspirated fluid and salient findings on CT scans, including periprosthetic soft-tissue mass, malpositioning of the prosthesis, periprosthetic osteolysis, reactive enlarged lymph nodes, and heterotopic ossification, were assessed by a blinded radiologist. RESULTS: Septic hip prosthesis was shown on revision surgery in 35 patients (36.4%), with Staphylococcus epidermidis isolated in 54.3% of cases. Culture of the aspirated fluid yielded the same microorganism in 24 patients (68.6%). The accuracy of preoperative CT-guided joint aspiration was 86.5%. High volume (>1 mL) of aspirated fluid was recorded in 32 patients (33.3%). In the multivariate analysis, high volume on CT aspiration, accumulation of soft tissue exceeding the joint margin, osteolysis without bone insufflation, and enlarged iliac lymph nodes were significant predictors of infected hip prosthesis. Similar results were obtained after adjustment of the model by the presence of aggressive granulomatosis. CONCLUSION: Preoperative CT-guided joint aspiration is accurate to diagnose septic hip prosthesis based on CT imaging findings and volume and bacterial culture of the aspirated fluid. Enlarged iliac lymph nodes emerged as a strong predictor of infection.

Whole-body MRI and pathological findings in adult patients with myopathies.

Magnetic resonance imaging (MRI) is considered the most sensitive and specific imaging technique for the detection of muscle diseases related to myopathies. Since 2008, the use of whole-body MRI (WBMRI) to evaluate myopathies has improved due to technical advances such as rolling table platform and parallel imaging, which enable rapid assessment of the entire musculoskeletal system with high-quality images. WBMRI protocols should include T1-weighted and short-tau inversion recovery (STIR), which provide the basic pulse sequences for studying myopathies, in order to detect fatty infiltration/muscle atrophy and muscle edema, respectively. High signal intensity in T1-weighted images shows chronic disease with fatty infiltration, whereas high signal intensity in STIR indicates an acute stage with muscle edema. Additional sequences such as diffusion-weighted imaging (DWI) can be readily incorporated into routine WBMRI study protocols. Contrast-enhanced sequences have not been done. This article reviews WBMRI as an imaging method to evaluate different myopathies (idiopathic inflammatory, dystrophic, non-dystrophic, metabolic, and channelopathies). WBMRI provides a comprehensive estimate of the total burden with a single study, seeking specific distribution patterns, including clinically silent involvement of muscle areas. Furthermore, WBMRI may help to select the "target muscle area" for biopsy during patient follow-up. It may be also be used to detect related and non-related pathological conditions, such as tumors.

Thoracic wall trauma-misdiagnosed lesions on radiographs and usefulness of ultrasound, multidetector computed tomography and magnetic resonance imaging.

Blunt injuries to the chest wall are an important chapter on emergency room (ER) departments, being the third most common injuries in trauma patients which ominous complications could appear. This article describes different types of traumatic events affecting the chest wall, which maybe misdiagnosed with conventional X-ray. Special emphasis has been done in computed tomography (CT) and multidetector CT (MDCT) imaging. This technique is considered the "gold-standard" for those traumatic patients, due to its fast acquisition covering the whole area of interest in axial plane, reconstructing multiplanar (2D, 3D) volume-rendered images with a superb quality and angiographic CT capabilities for evaluating vascular damage. Complementary techniques such as ultrasonography (US) and magnetic resonance imaging (MRI) may improve the diagnostic accuracy due to its great capacity in visualising soft-tissue trauma (muscle-tendinous tears) and subtle fractures. All these imaging methods have an important role in quantifying the severity of chest wall trauma. The findings of this study have been exposed with cases of our archives in a didactic way.

Hypertrophy of the tensor fascia lata muscle as a complication of total hip arthroplasty.

INTRODUCTION: Hypertrophy of the tensor fascia lata muscle (HTFLM) is a rare complication after total hip arthroplasty (THA) and is a potential source of pain, palpable mass, or both. MATERIALS AND METHODS: We retrospectively analyzed 1285 primary THAs and 482 THA revisions (THAR) performed at our center from 2008 to 2014. Among these, five patients had HTFLM (average age 68.8 years). The type of surgery and symptoms were evaluated, as were imaging studies (CT or MRI) of both hips (10 hips), and functional outcomes with the Merle d'Aubigné score. RESULTS: The suspected diagnosis was established at an average of 30.2 months after surgery. Four cases occurred after THA and one case after THAR. A modified Hardinge approach was used in four cases and a Röttinger approach in one case. Two cases had pain and palpable mass in the trochanteric region and three cases only pain. The asymmetric HTFLM of the THA side against the nonsurgical side was confirmed by measuring the cross section of the tensor fascia lata muscle on imaging. The sartorius muscle was measured for reference in each case. The Merle d'Aubigne scale had a mean value of 16.6 (range 13-18) at 38 months after the procedure. CONCLUSIONS: HTFLM after THA is a benign condition that could be mistaken for a tumor when presenting as a palpable mass. We propose that it should be considered in the differential diagnosis of pain in the lateral aspect of hips that have previously undergone THA.

Accuracy of CT-guided joint aspiration in patients with suspected infection status post-total hip arthroplasty.

OBJECTIVE: To determine the accuracy of guided computed tomography aspiration in the detection of septic hip prosthesis before surgery. MATERIALS AND METHODS: Sixty-three patients (35 women and 28 men; age range, 29-86 years; mean age, 71 years) with clinically suspected septic hip prosthesis were prospectively studied with independent review board (IRB) approval. Volume and microbiological cultures of aspirated fluid and several computed tomography imaging findings such as periprosthetic fluid collections, prosthetic acetabular malposition, and heterotopic ossification were analyzed. All patients underwent revision surgery and infection was finally diagnosed in 33 patients. RESULTS: Statistical comparative analysis was performed comparing computed tomography aspiration and surgical findings (95% CI; level of significance at P=0.05 two-sided) with 70% sensitivity, 100% specificity, 84% accuracy, 100% positive predictive value, and 75% negative predictive value. Using Fisher's exact test, the presence of periprosthetic fluid collections (P=0.001), prosthetic acetabular malposition (P=0.025) and aspirated fluid volume (P=0.009) were significantly higher in infected than in non-infected prostheses, whereas heterotopic ossification was not (P=0.429). CONCLUSION: Computed tomography aspiration is accurate to preoperatively diagnose septic hip prosthesis on the basis of volume and bacterial cultures of aspirated joint fluid. Furthermore, imaging findings such as periprosthetic fluid collections and prosthetic acetabular malposition strongly suggest infected prosthesis.

Sacroilíacas: artrosis o artritis / Sacroiliac joints: osteoarthritis or arthritis

Uno de los principales retos en el tratamiento del dolor de la articulación sacroilíaca (AS) es llegar a un adecuado diagnóstico. Las técnicas por imagen han ganado un gran protagonismo en este aspecto. La tomografía computarizada (TC) y la resonancia magnética (RM) presentan igual eficacia en la detección de cambios estructurales en artrosis y artritis, y ambas son muy superiores a la radiografía simple, la cual puede retrasar el diagnóstico. Además, la RM puede mostrar incipientes cambios en el cartílago y actividad inflamatoria aguda en el hueso subcondral y ligamentos en las espondiloartropatías y las infiltraciones subperiósticas y transcapsulares periarticulares características de la artritis séptica, que no pueden detectarse por TC ni en imágenes radiográficas. Las secuencias potenciadas en T1 con supresión de la grasa y STIR en los estudios de RM son más sensibles para demostrar erosiones y cambios inflamatorios, respectivamente. Las imágenes potenciadas en T1 con supresión de la grasa y tras la administración intravenosa de contraste en las artritis sépticas definirán la extensión de los cambios infecciosos y diferenciarán abscesos; en las espondiloartropatías pueden ser útiles, aunque su uso es controvertido. La gammagrafía ósea es sensible en artritis activas de inicio, pero poco específica debido a la actividad normal de esta articulación, aunque con radiofármacos específicos es útil para confirmar una artritis séptica y descartar otros focos infecciosos. Esta compleja articulación de movilidad limitada muestra un amplio espectro de variaciones y cambios degenerativos a lo largo de la vida, y es necesario conocerlas para facilitar la interpretación de las imágenes y realizar un adecuado diagnóstico de enfermedad (AU)

One of the most challenging aspects of treating the sacroiliac joint (SIJ) pain is the complexity of diagnosis. Imaging methods have gained importance for the diagnosis of SIJ diseases. CT and MR exams had equal efficacy superior to radiography in staging structural changes in the SIJ due to osteoarthritis or sacroiliitis. The diagnosis of spondyloarthropaty can be delayed for several years using certain radiography studies. MR imaging reveal early cartilage changes and active inflammatory changes in the subchondral bone and surrounding ligaments in spondyloarthropaties, as well as subperiosteal and transcapsular yuxtaarticular infiltrations characteristic of septic sacroiliitis, which could not be found by either CT of radiography. T1-WI with fat suppression (FS) and STIR images improve the demonstration of erosions and inflammatory changes respectively, on MR studies. Additional T1-FS after i.v. contrast has proven valuable in demonstrating the extension of inflammatory changes and abscesses in septic sacroiliitis, and in spondyloartropaties may be useful although this is debatable. Scintigraphy gives high sensibility only in early inflammatory changes and low specificity for the diagnosis of sacroiliitis due to high bone turnover in the SIJ, although specific radioprobes are useful in confirming the septic etiology and evaluating additional foci. This complex joint of very limited mobility shows a lot of structural variations and some anatomical degenerative changes due to age, which are necessary to know to an adequate image interpretation and diagnosis of disease (AU)

[Sacroiliac joints: osteoarthritis or arthritis]. / Sacroilíacas: artrosis o artritis.

One of the most challenging aspects of treating the sacroiliac joint (SIJ) pain is the complexity of diagnosis. Imaging methods have gained importance for the diagnosis of SIJ diseases. CT and MR exams had equal efficacy superior to radiography in staging structural changes in the SIJ due to osteoarthritis or sacroiliitis. The diagnosis of spondyloarthropaty can be delayed for several years using certain radiography studies. MR imaging reveal early cartilage changes and active inflammatory changes in the subchondral bone and surrounding ligaments in spondyloarthropaties, as well as subperiosteal and transcapsular yuxtaarticular infiltrations characteristic of septic sacroiliitis, which could not be found by either CT of radiography. T1-WI with fat suppression (FS) and STIR images improve the demonstration of erosions and inflammatory changes respectively, on MR studies. Additional T1-FS after i.v. contrast has proven valuable in demonstrating the extension of inflammatory changes and abscesses in septic sacroiliitis, and in spondyloartropaties may be useful although this is debatable. Scintigraphy gives high sensibility only in early inflammatory changes and low specificity for the diagnosis of sacroiliitis due to high bone turnover in the SIJ, although specific radioprobes are useful in confirming the septic etiology and evaluating additional foci. This complex joint of very limited mobility shows a lot of structural variations and some anatomical degenerative changes due to age, which are necessary to know to an adequate image interpretation and diagnosis of disease.

Resonancia magnética de las plastías del ligamento cruzado anterior de rodilla / Magnetic resonance of anterior cruciate ligament of the knee

Proponemos un protocolo de estudio de resonancia magnética (RM) que optimiza la valoración de los injertos de Ligamento Cruzado Anterior (LCA) de la rodilla. Se estudiaron 12 rodillas con una plastia de tendón rotuliano hueso-tendón-hueso, al protocolo habitual se añadieron planos oblicuos siguiendo la dirección del injerto, planos coronales y secuencias tras la adminsitración de gadolinio. En ocho pacientes se mejoró la visualización del injerto en los planos oblicuos. Se observó un realce periférico del injerto en ocho casos, favoreciendo la visualización de su límite en cuatro de ellos, y en dos pacientes con exploración anormal se constató un tejido vascularizado hipertrófico. En los planos coronales se demostró en un caso el espacio intercondíleo estrecho. Existen diferencias morfológicas entre una ligamentoplastía y un LCA nativo que dificultan su estudio mediante RM. La introducción de secuencias oblicuas y con gadolinio puede favorecer su visualización. Es necesario complementarlo con planos coronales para estudiar su relaciones con estructuras laterales