This document discusses imaging modalities for evaluating diabetic foot complications. It notes that foot sepsis is a major cause of mortality in diabetes patients in India. Clinical examination alone may be deceptive, so imaging is important. Useful imaging modalities include X-ray, ultrasound, Doppler, DSA, CT, MRI, bone scintigraphy and DEXA. Leukocyte-labeled scans and MRI are particularly helpful for diagnosing osteomyelitis in the foot. Overall, imaging plays an important role in evaluating foot complications given that clinical examination has limitations on its own.

1. Imaging in Diabetic footImaging in Diabetic foot
Department of EndocrinologyDepartment of Endocrinology
Postgraduate Institute of Medical Education and ResearchPostgraduate Institute of Medical Education and Research
ChandigarhChandigarh
Dr. Anil Bhansali

5. Mortality in DMMortality in DM
Western WorldWestern World
 Coronary artery diseaseCoronary artery disease 50-60%50-60%
 End stage renal diseaseEnd stage renal disease 30-40%30-40%
IndiaIndia
a) Sepsisa) Sepsis 46.5%46.5%
- Pulmonary- Pulmonary 21%21%
- Foot- Foot 8.3%8.3%
- Others- Others 17%17%
b) CADb) CAD 17.4%17.4%
c) ESRDc) ESRD 9.7%9.7%
Bhansali et al, Diab Res Clin Prac 2003

6. Why Imaging?Why Imaging?
 Sensorymotor neuropathySensorymotor neuropathy
 VasculopathyVasculopathy
 Lazy leukocyte syndromeLazy leukocyte syndrome
 Alters signs of inflammationAlters signs of inflammation
 Clinical examination may be deceptiveClinical examination may be deceptive

7. Imaging modalitiesImaging modalities
 X-rayX-ray
 UltrasonographyUltrasonography
 Vascular DopplerVascular Doppler
 DSADSA
 CTCT
 MRIMRI
 Bone ScintigraphyBone Scintigraphy
 DEXADEXA

8. Major IssuesMajor Issues
 ForefootForefoot
-- UlcerationUlceration
-- OsteomyelitisOsteomyelitis
 Mid and HindfootMid and Hindfoot
- Charcot’s jointCharcot’s joint
(with or without infection)(with or without infection)

10. X-ray FootX-ray Foot
 Soft tissue swellingSoft tissue swelling
 Foreign bodyForeign body
 Gas gangreneGas gangrene
 Vascular calcificationVascular calcification
 Loss of foot archLoss of foot arch
 Charcot’s arthropathyCharcot’s arthropathy
 AmputationsAmputations
 OsteomyelitisOsteomyelitis

18. Limitations of X-rayLimitations of X-ray
 OsteomyelitisOsteomyelitis
-- Demineralization, periosteal reactions andDemineralization, periosteal reactions and
bony destructionbony destruction
 30-50% of bone destruction30-50% of bone destruction
 Accuracy 50-60%Accuracy 50-60%

20. UltrasonographyUltrasonography
 Plantar abscessPlantar abscess
 Soft tissue collectionSoft tissue collection
 Associated DVTAssociated DVT

21. Doppler ImagingDoppler Imaging
 Vascular statusVascular status
 Site and extent of obstructionSite and extent of obstruction
 CollateralsCollaterals

26. DSADSA
 Better delineation than dopplerBetter delineation than doppler
 Higher sensitivityHigher sensitivity
 Before revascularisation procedure –Before revascularisation procedure –
mandatorymandatory
 Contrast induced nephropathyContrast induced nephropathy

29. Foot CT scanFoot CT scan
 Intraosseous gasIntraosseous gas
 SequestrumSequestrum
 Cortical bone defectsCortical bone defects
 Periosteal new bone formationPeriosteal new bone formation

34. Limitations of CT scanLimitations of CT scan
 SuppurationSuppuration
 Tissue edemaTissue edema
 Tissue fibrosisTissue fibrosis
 Granulomatous tissuesGranulomatous tissues

35. Foot: MR ImagingFoot: MR Imaging
 Anatomical detailsAnatomical details
 Osteomyelitis (Abnormal marrow signal,Osteomyelitis (Abnormal marrow signal,
soft tissue mass and cortical destruction)soft tissue mass and cortical destruction)
 Neuropathic jointNeuropathic joint
-- Disorganised destruction, dislocation,Disorganised destruction, dislocation,
marrow edema, effusion, loss of jointmarrow edema, effusion, loss of joint
definitiondefinition

36. Limitations of MRI ImagingLimitations of MRI Imaging
 Reactive marrow edema vs osteomyelitisReactive marrow edema vs osteomyelitis
 Hyperintensity on T2WI -marrow edemaHyperintensity on T2WI -marrow edema
 ExpensiveExpensive

39. Bone scintigraphyBone scintigraphy
 99m99m
Tc MDP scanTc MDP scan
 Leucocyte scan (HMPAO-Leu)Leucocyte scan (HMPAO-Leu)
 Ciproflox scanCiproflox scan
 Marrow scanMarrow scan
 Radioabelled monoclonal antibodiesRadioabelled monoclonal antibodies

40. 99m99m
Tc MDP ScanTc MDP Scan
 OsteomyelitisOsteomyelitis
-- Sensitivity 100%Sensitivity 100%
-- Specificity 30%Specificity 30%
 Non-infective inflammationNon-infective inflammation
 NeuroarthropathyNeuroarthropathy
 Traumatic fracturesTraumatic fractures

41. 99m99m
Tc Ciproflox ScanTc Ciproflox Scan
 OsteomyelitisOsteomyelitis
 Bone specificBone specific
(sensitivity and specificity 90%)(sensitivity and specificity 90%)
 Ciplox sensitive organismCiplox sensitive organism
 Negative in sterile inflammationNegative in sterile inflammation
Bhansali and Dutta et al, Diab Res Clin Prac 2004

50. DEXADEXA
 Diabetic osteopathyDiabetic osteopathy
 Useful for monitoring bisphosphonateUseful for monitoring bisphosphonate
therapytherapy

51. ConclusionConclusion
 Foot sepsis is an important cause ofFoot sepsis is an important cause of
morbidity and mortalitymorbidity and mortality
 Clinical examination is not a substitute forClinical examination is not a substitute for
imagingimaging
 Leucocyte labelled scan and MRI areLeucocyte labelled scan and MRI are
useful modalities for diagnosinguseful modalities for diagnosing
osteomyelitisosteomyelitis