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Overview
Osteomyelitis versus Charcot
Osteomyelitis
Charcot neuro-osteoarthropathy
Acute Charcot
Chronic Charcot
MRI protocol
Publicationdate March 6, 2011
Diabetes-related foot problems like osteomyelitis and Charcot neuro-osteoarthropathy are
associated with a high morbidity and high healthcare costs.
A red hot foot in a patient with diabetic neuropathy is a diagnostic problem.
In this overview we will focus on two questions:
Overview
Osteomyelitis versus Charcot
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.
Chronic stage of Charcot:
The chronic stage of Charcot no longer shows a warm and red foot, but the edema usually
persists.
Joint deformity, subluxation and dislocation of the metatarsals lead to a rocker-bottom type
deformity in which the cuboid becomes a weight-bearing structure.
The deformity of the foot with abnormal pressure distribution on the plantar surface coupled
with reduced or loss of sensation, makes the foot vulnerable and leads to callus and blister
formation aswell as foot ulceration.
Charcot with superimposed osteomyelitis:
Foot ulceration can subsequently lead to infections, such as cellulitis and osteomyelitis, and
this may eventually lead to amputation.
The simplest method to determine whether osteomyelitis is present is to follow the path of an
ulcer or sinus tract to the bone and evaluate the signal intensity of the bone marrow (1).
Osteomyelitis in chronic Charcot is usually located in the midfoot, while osteomyelitis in
diabetic neuropathy without Charcot is usually in the forefoot and hindfoot.
Osteomyelitis
While diagnosing osteomyelitis is important, it is unfortunately also difficult.
Clinical and laboratory signs and symptoms are generally unhelpful.
The clinical diagnosis relies on the identification and characterization of an associated foot
ulcer, a method that is often unreliable.
It is important to mark the skin or subcutaneous abnormality, i.e. ulcer or sinus tract and to
find its relation to the area of bone abnormality.
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 neuroosteoarthropathy
Acute Charcot neuro-osteoarthropathy of the midfoot
Subarticular marrow
edema in the midfoot
Subcutaneous soft
tissues are relatively
uninvolved.
Acute 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.
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 neuroosteoarthropathy 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.
Osteomyelitis in chronic Charcot neuro-osteoarthropathy
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.
No osteomyelitis in chronic Charcot neuro-osteoarthropathy
On the left a patient with Charcot neuro-osteoarthropathy with a subcutaneous fistula tract
(arrow).
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.
1. Use of MR Imaging in Diagnosing Diabetes-related Pedal Osteomyelitis
by Andrea Donovan, MD and Mark E. Schweitzer, MD
May 2010 RadioGraphics, 30, 723-736.
2. Charcot Arthropathy in e-medicine
3. Charcot osteoarthropathy of the foot (PDF)
by Byron M Perrin et al
Australian Family Physician Vol.39 no.3 march2010
4. Neuro-osteoarthropathy of the Foot. Radiologist: Friend or Foe?
by Ivo G. Schoots et al
Semin Musculoskelet Radiol 2010;14:365-376.