Skeletal Radiology

, Volume 47, Issue 10, pp 1337–1347 | Cite as

Dynamic contrast-enhanced magnetic resonance imaging for differentiating osteomyelitis from acute neuropathic arthropathy in the complicated diabetic foot

  • Dan Liao
  • Liqiu Xie
  • Yongliang Han
  • Silin Du
  • Hansheng Wang
  • Chun Zeng
  • Yongmei Li
Scientific Article



The main purpose of this study was to investigate the diagnostic value of dynamic contrast-enhanced MRI (DCE-MRI) in differentiating osteomyelitis from acute neuropathic arthropathy in the diabetic foot.

Materials and Methods

This prospective study was carried out on 30 diabetic foot patients, with a mean age of 51 years. The patients all underwent clinical examinations, laboratory examinations and DCE-MRI. The DCE-MRI parameters (Ktrans, Kep and Ve) of the regions of acute neuropathic arthropathy and osteomyelitis were calculated. Receiver operating characteristic curves (ROCs) were used to identify the DCE-MRI parameters that showed the highest accuracy in differentiating the acute neuropathic arthropathy from the osteomyelitic regions. Pearson correlation coefficients were used to assess the correlations among the DCE-MRI parameters, the level of C-reactive protein (CRP) and the erythrocyte sedimentation rate (ESR).


The Ktrans, Kep and Ve values of the osteomyelitic regions were higher than those of the acute neuropathic arthropathy regions, and significant differences were found between the two groups (P = 0.000, P = 0.000, P = 0.000). The ROC analysis showed that Ktrans and Ve performed best in differentiating osteomyelitis from acute neuropathic arthropathy, both with an area under the curve of 0.938. The Pearson correlation coefficients showed that the DCE-MRI parameters correlated significantly with the level of CRP and ESR (P = 0.000, P = 0.014, P = 0.000; P = 0.000, P = 0.000, P = 0.013).


Our results showed that DCE-MRI may provide reproducible parameters that can reliably differentiate osteomyelitis from acute neuropathic arthropathy.


Diabetic foot Osteomyelitis Neuropathic arthropathy Dynamic contrast-enhanced imaging C-reactive protein Erythrocyte sedimentation rate 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.

Source of support



  1. 1.
    Markanday A. Diagnosing diabetic foot osteomyelitis: narrative review and a suggested 2-step score-based diagnostic pathway for clinicians. Open Forum Infect Dis. 2014;1(2):ofu060.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Martin Noguerol T, Luna Alcala A, Beltran LS, Gomez Cabrera M, Broncano Cabrero J, Vilanova JC. Advanced MR imaging techniques for differentiation of neuropathic arthropathy and osteomyelitis in the diabetic foot. Radiographics. 2017;37(4):1161–80.CrossRefPubMedGoogle Scholar
  3. 3.
    Aragon-Sanchez J, Lazaro-Martinez JL, Hernandez-Herrero C, Campillo-Vilorio N, Quintana-Marrero Y, Garcia-Morales E, et al. Does osteomyelitis in the feet of patients with diabetes really recur after surgical treatment? Natural history of a surgical series. Diabet Med. 2012;29(6):813–8.CrossRefPubMedGoogle Scholar
  4. 4.
    Faglia E, Clerici G, Caminiti M, Curci V, Somalvico F. Influence of osteomyelitis location in the foot of diabetic patients with transtibial amputation. Foot Ankle Int. 2013;34(2):222–7.CrossRefPubMedGoogle Scholar
  5. 5.
    Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2012;54(12):e132–73.CrossRefPubMedGoogle Scholar
  6. 6.
    Game FL. Osteomyelitis in the diabetic foot: diagnosis and management. Med Clin North Am. 2013;97(5):947–56.CrossRefPubMedGoogle Scholar
  7. 7.
    Ertugrul BM, Lipsky BA, Savk O. Osteomyelitis or Charcot neuro-osteoarthropathy? Differentiating these disorders in diabetic patients with a foot problem. Diabetic Foot Ankle 2013; Scholar
  8. 8.
    Wukich DK, Raspovic KM, Hobizal KB, Rosario B. Radiographic analysis of diabetic midfoot Charcot neuroarthropathy with and without midfoot ulceration. Foot Ankle Int. 2014;35(11):1108–15.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Hectors SJ, Besa C, Wagner M, Jajamovich GH, Haines GK 3rd, Lewis S, et al. DCE-MRI of the prostate using shutter-speed vs. Tofts model for tumor characterization and assessment of aggressiveness. J Magn Reson Imaging. 2017;46(3):837–49.CrossRefPubMedGoogle Scholar
  10. 10.
    Yan S, Wang Z, Li L, Guo Y, Ji X, Ni H, et al. Characterization of cervical lymph nodes using DCE-MRI: differentiation between metastases from SCC of head and neck and benign lymph nodes. Clin Hemorheol Microcirc. 2016;64(2):213–22.CrossRefPubMedGoogle Scholar
  11. 11.
    Zhang J, Zuo PL, Cheng KB, Yu AH, Cheng XG. Feasibility study of dynamic contrast enhanced magnetic resonance imaging qualitative diagnosis of musculoskeletal tumors. Beijing Da Xue Xue Bao Yi Xue Ban. 2016;48(2):287–91.PubMedGoogle Scholar
  12. 12.
    Sujlana P, Skrok J, Fayad LM. Review of dynamic contrast-enhanced MRI: technical aspects and applications in the musculoskeletal system. J Magn Reson Imaging. 2018;47(4):875–90.CrossRefPubMedGoogle Scholar
  13. 13.
    Biffar A, Sourbron S, Dietrich O, Schmidt G, Ingrisch M, Reiser MF, et al. Combined diffusion-weighted and dynamic contrast-enhanced imaging of patients with acute osteoporotic vertebral fractures. Eur J Radiol. 2010;76(3):298–303.CrossRefPubMedGoogle Scholar
  14. 14.
    Lang N, Su MY, Yu HJ, Yuan H. Differentiation of tuberculosis and metastatic cancer in the spine using dynamic contrast-enhanced MRI. Eur Spine J. 2015;24(8):1729–37.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Manganaro L, Saldari M, Pozza C, Vinci V, Gianfrilli D, Greco E, et al. Dynamic contrast-enhanced and diffusion-weighted MR imaging in the characterisation of small, non-palpable solid testicular tumours. Eur Radiol. 2018;28(2):554–64.CrossRefPubMedGoogle Scholar
  16. 16.
    Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. J Am Podiatr Med Assoc. 2013;103(1):2–7.CrossRefPubMedGoogle Scholar
  17. 17.
    Ertugrul BM, Savk O, Ozturk B, Cobanoglu M, Oncu S, Sakarya S. The diagnosis of diabetic foot osteomyelitis: examination findings and laboratory values. Med Sci Monit. 2009;15(6):CR307–12.PubMedGoogle Scholar
  18. 18.
    Dinh MT, Abad CL, Safdar N. Diagnostic accuracy of the physical examination and imaging tests for osteomyelitis underlying diabetic foot ulcers: meta-analysis. Clin Infect Dis. 2008;47(4):519–27.CrossRefPubMedGoogle Scholar
  19. 19.
    Low KT, Peh WC. Magnetic resonance imaging of diabetic foot complications. Singapore Med J. 2015;56(01):23–34.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Fridman R, Bar-David T, Kamen S, Staron RB, Leung DK, Rasiej MJ. Imaging of diabetic foot infections. Clin Podiatr Med Surg. 2014;31(1):43–56.CrossRefPubMedGoogle Scholar
  21. 21.
    Harish S, Chiavaras MM, Kotnis N, Rebello R. MR imaging of skeletal soft tissue infection: utility of diffusion-weighted imaging in detecting abscess formation. Skeletal Radiol. 2011;40(3):285–94.CrossRefPubMedGoogle Scholar
  22. 22.
    Leone A, Cassar-Pullicino VN, Semprini A, Tonetti L, Magarelli N, Colosimo C. Neuropathic osteoarthropathy with and without superimposed osteomyelitis in patients with a diabetic foot. Skeletal Radiol. 2016;45(6):735–54.CrossRefPubMedGoogle Scholar
  23. 23.
    Mahendra M, Singh R. Diagnostic accuracy and surgical utility of MRI in complicated diabetic foot. J Clin Diagn Res. 2017;11(7):RC01–4.PubMedPubMedCentralGoogle Scholar
  24. 24.
    Wendl CM, Muller S, Meier J, Fellner C, Eiglsperger J, Gosau M, et al. High resolution contrast-enhanced ultrasound and 3-tesla dynamic contrast-enhanced magnetic resonance imaging for the preoperative characterization of cervical lymph nodes: first results. Clin Hemorheol Microcirc. 2012;52(2–4):153–66.PubMedGoogle Scholar
  25. 25.
    Jansen JF, Schoder H, Lee NY, Stambuk HE, Wang Y, Fury MG, et al. Tumor metabolism and perfusion in head and neck squamous cell carcinoma: pretreatment multimodality imaging with 1H magnetic resonance spectroscopy, dynamic contrast-enhanced MRI, and [18F]FDG-PET. Int J Radiat Oncol Biol Phys. 2012;82(1):299–307.CrossRefPubMedGoogle Scholar
  26. 26.
    Zhu J, Zhang F, Zhou J, Li H. Assessment of therapeutic response in Crohn's disease using quantitative dynamic contrast enhanced MRI (DCE-MRI) parameters: a preliminary study. Medicine. 2017;96(32):e7759.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Jans L, De Coninck T, Wittoek R, Lambrecht V, Huysse W, Verbruggen G, et al. 3 T DCE-MRI assessment of synovitis of the interphalangeal joints in patients with erosive osteoarthritis for treatment response monitoring. Skeletal Radiol. 2013;42(2):255–60.CrossRefPubMedGoogle Scholar
  28. 28.
    Versluis B, Dremmen MH, Nelemans PJ, Wildberger JE, Schurink GW, Leiner T, et al. Dynamic contrast-enhanced MRI assessment of hyperemic fractional microvascular blood plasma volume in peripheral arterial disease: initial findings. PLoS One. 2012;7(5):e37756.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Zampa V, Bargellini I, Rizzo L, Turini F, Ortori S, Piaggesi A, et al. Role of dynamic MRI in the follow-up of acute Charcot foot in patients with diabetes mellitus. Skeletal Radiol. 2011;40(8):991–9.CrossRefPubMedGoogle Scholar
  30. 30.
    Abdel Razek AAK, Samir S. Diagnostic performance of diffusion-weighted MR imaging in differentiation of diabetic osteoarthropathy and osteomyelitis in diabetic foot. Eur J Radiol. 2017;89:221–5.CrossRefPubMedGoogle Scholar
  31. 31.
    Demirev A, Weijers R, Geurts J, Mottaghy F, Walenkamp G, Brans B. Comparison of [18 F]FDG PET/CT and MRI in the diagnosis of active osteomyelitis. Skeletal Radiol. 2014;43(5):665–72.CrossRefPubMedGoogle Scholar
  32. 32.
    Zhang M, Zhou L, Huang N, Zeng H, Liu S, Liu L. Assessment of active and inactive sacroiliitis in patients with ankylosing spondylitis using quantitative dynamic contrast-enhanced MRI. J Magn Reson Imaging. 2017;46(1):71–8.CrossRefPubMedGoogle Scholar
  33. 33.
    Van Asten SA, Jupiter DC, Mithani M, La Fontaine J, Davis KE, Lavery LA. Erythrocyte sedimentation rate and C-reactive protein to monitor treatment outcomes in diabetic foot osteomyelitis. Int Wound J. 2017;14(1):142–8.Google Scholar
  34. 34.
    Boulton AJ. The pathway to foot ulceration in diabetes. Med Clin North Am. 2013;97(5):775–90.CrossRefPubMedGoogle Scholar

Copyright information

© ISS 2018

Authors and Affiliations

  • Dan Liao
    • 1
  • Liqiu Xie
    • 1
  • Yongliang Han
    • 1
  • Silin Du
    • 1
  • Hansheng Wang
    • 1
  • Chun Zeng
    • 1
  • Yongmei Li
    • 1
  1. 1.Department of RadiologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina

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