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Neuropathic Arthropathy of the Foot with and without Superimposed Osteomyelitis: MR Imaging Characteristics¹

¹ From Drexel University College of Medicine, Philadelphia, Pa (M.E.A.); Departments of Radiology (W.B.M.) and Orthopedic Surgery, Rothman Institute (S.M.R.), Thomas Jefferson University Hospital, 111 S 11th St, Suite 3390, Philadelphia, PA 19107; Department of Radiology, Brigham and Women's Hospital, Boston, Mass (J.A.C.); Department of Radiology, Hospital for Joint Disease, New York University, New York, NY (M.E.S.); and Radiologisches Institut, Universitatsspital Basel, Basel, Switzerland (H.P.L.). Received August 10, 2004; revision requested October 19; revision received February 14, 2005; accepted March 10; final version accepted April 28. Address correspondence to W.B.M. (e-mail: William.Morrison{at}Jefferson.edu).

View larger version (128K): [in a new window]   Figure 1a: MR images show thick rim enhancement of joint fluid in a 55-year-old man with neuropathic arthropathy and surgically documented superimposed septic arthritis and osteomyelitis. (a) Sagittal fast spin echo IR image (4817/75/150) shows effusion of the fourth metatarsophalangeal joint (arrow), which is subluxed. (b) Corresponding sagittal T1-weighted fat-suppressed postcontrast fast multiplanar spoiled GRE image (250/2) shows thick rim enhancement (arrow) of the joint fluid. Note the presence of an ulcer and sinus tract (arrowhead).

View larger version (100K): [in a new window]   Figure 1b: MR images show thick rim enhancement of joint fluid in a 55-year-old man with neuropathic arthropathy and surgically documented superimposed septic arthritis and osteomyelitis. (a) Sagittal fast spin echo IR image (4817/75/150) shows effusion of the fourth metatarsophalangeal joint (arrow), which is subluxed. (b) Corresponding sagittal T1-weighted fat-suppressed postcontrast fast multiplanar spoiled GRE image (250/2) shows thick rim enhancement (arrow) of the joint fluid. Note the presence of an ulcer and sinus tract (arrowhead).

View larger version (107K): [in a new window]   Figure 2a: MR images show joint erosion. (a) Sagittal fast spin-echo IR image (5100/45/150) of the midfoot of a 52-year-old man with neuropathic arthropathy of the Lisfranc joint shows mild subchondral edema (arrowhead) but preservation of the articular surfaces. (b) Follow-up sagittal T1-weighted fat-suppressed postcontrast fast multiplanar spoiled GRE MR image (333/2) obtained in the same patient 16 months later shows erosion of the joint margin (arrowhead). Superimposed osteomyelitis was documented at biopsy of the first metatarsal base and cuneiform. Note also discrete marrow enhancement, extending 2.0 cm from the metatarsal articular surface (long arrow) and diffusely involving the cuneiform (short arrow).

View larger version (103K): [in a new window]   Figure 2b: MR images show joint erosion. (a) Sagittal fast spin-echo IR image (5100/45/150) of the midfoot of a 52-year-old man with neuropathic arthropathy of the Lisfranc joint shows mild subchondral edema (arrowhead) but preservation of the articular surfaces. (b) Follow-up sagittal T1-weighted fat-suppressed postcontrast fast multiplanar spoiled GRE MR image (333/2) obtained in the same patient 16 months later shows erosion of the joint margin (arrowhead). Superimposed osteomyelitis was documented at biopsy of the first metatarsal base and cuneiform. Note also discrete marrow enhancement, extending 2.0 cm from the metatarsal articular surface (long arrow) and diffusely involving the cuneiform (short arrow).

View larger version (71K): [in a new window]   Figure 3a: MR images show subcutaneous fat replacement. (a) Sagittal T1-weighted image (500/10) of the midfoot of a 54-year-old man shows preservation of fat signal intensity in the subcutaneous tissues. (b) Sagittal T1-weighted image (600/10) of the foot of the same patient 12 months later shows replacement of the subcutaneous fat signal intensity (arrows); at this time osteomyelitis was confirmed at biopsy of the cuboid.

View larger version (58K): [in a new window]   Figure 3b: MR images show subcutaneous fat replacement. (a) Sagittal T1-weighted image (500/10) of the midfoot of a 54-year-old man shows preservation of fat signal intensity in the subcutaneous tissues. (b) Sagittal T1-weighted image (600/10) of the foot of the same patient 12 months later shows replacement of the subcutaneous fat signal intensity (arrows); at this time osteomyelitis was confirmed at biopsy of the cuboid.

View larger version (131K): [in a new window]   Figure 4a: MR images show soft-tissue enhancement. (a) Coronal T1-weighted fat-suppressed postcontrast fast multiplanar spoiled GRE image (250/2) obtained in a 52-year-old man with neuropathic arthropathy of the midfoot shows a small cutaneous ulcer (arrow) and enhancement of the surrounding subcutaneous tissues (arrowheads). The patient's condition responded to conservative management. (b) Another coronal T1-weighted fat-suppressed postcontrast fast multiplanar spoiled GRE image (280/2) obtained 17 months later for suspicion of osteomyelitis shows recurrent ulceration (white arrow) and both subcutaneous and periarticular enhancement (arrowheads). Biopsy of the medial cuneiform subsequently proved the presence of osteomyelitis. Note diffuse enhancement of the first and second cuneiforms (black arrows).

View larger version (161K): [in a new window]   Figure 4b: MR images show soft-tissue enhancement. (a) Coronal T1-weighted fat-suppressed postcontrast fast multiplanar spoiled GRE image (250/2) obtained in a 52-year-old man with neuropathic arthropathy of the midfoot shows a small cutaneous ulcer (arrow) and enhancement of the surrounding subcutaneous tissues (arrowheads). The patient's condition responded to conservative management. (b) Another coronal T1-weighted fat-suppressed postcontrast fast multiplanar spoiled GRE image (280/2) obtained 17 months later for suspicion of osteomyelitis shows recurrent ulceration (white arrow) and both subcutaneous and periarticular enhancement (arrowheads). Biopsy of the medial cuneiform subsequently proved the presence of osteomyelitis. Note diffuse enhancement of the first and second cuneiforms (black arrows).

View larger version (119K): [in a new window]   Figure 5a: MR images show development of a sinus tract. (a) Sagittal T1-weighted fat-suppressed postcontrast fast multiplanar spoiled GRE image (230/2) obtained in a 60-year-old man with neuropathic arthropathy of the midfoot and hindfoot shows multiple joint subluxations with subcutaneous enhancement only (arrow). (b) Twelve months later the patient presented with a draining plantar ulcer; another sagittal T1-weighted fat-suppressed postcontrast fast multiplanar spoiled GRE image (280/2) shows a tram-track pattern of soft-tissue enhancement representing a sinus tract (arrowheads) leading to the cuboid (arrow), which demonstrates enhancement proved to represent osteomyelitis at surgery.

View larger version (114K): [in a new window]   Figure 5b: MR images show development of a sinus tract. (a) Sagittal T1-weighted fat-suppressed postcontrast fast multiplanar spoiled GRE image (230/2) obtained in a 60-year-old man with neuropathic arthropathy of the midfoot and hindfoot shows multiple joint subluxations with subcutaneous enhancement only (arrow). (b) Twelve months later the patient presented with a draining plantar ulcer; another sagittal T1-weighted fat-suppressed postcontrast fast multiplanar spoiled GRE image (280/2) shows a tram-track pattern of soft-tissue enhancement representing a sinus tract (arrowheads) leading to the cuboid (arrow), which demonstrates enhancement proved to represent osteomyelitis at surgery.

View larger version (131K): [in a new window]   Figure 6a: MR images show disappearance of subchondral cysts. (a) Sagittal fast spin-echo IR image (5000/70/150) obtained in a 55-year-old man with neuropathic arthropathy of the Lisfranc joint shows subchondral cysts (arrowheads); at this time there was no clinical suspicion of infection. (b) MR imaging was performed again in the same patient after 11 months, after development of a draining sinus tract originating from the midfoot; sagittal fast spin-echo IR image (4817/75/150) of the same area shows disappearance of the subchondral cysts, erosion and destruction of the joint (arrows), and diffuse marrow edema in the bones of the midfoot and hindfoot, which was subsequently proved to represent osteomyelitis.

View larger version (167K): [in a new window]   Figure 6b: MR images show disappearance of subchondral cysts. (a) Sagittal fast spin-echo IR image (5000/70/150) obtained in a 55-year-old man with neuropathic arthropathy of the Lisfranc joint shows subchondral cysts (arrowheads); at this time there was no clinical suspicion of infection. (b) MR imaging was performed again in the same patient after 11 months, after development of a draining sinus tract originating from the midfoot; sagittal fast spin-echo IR image (4817/75/150) of the same area shows disappearance of the subchondral cysts, erosion and destruction of the joint (arrows), and diffuse marrow edema in the bones of the midfoot and hindfoot, which was subsequently proved to represent osteomyelitis.