A narrative review of the measurement methods for biomechanical properties of plantar soft tissue in patients with diabetic foot.

This article provides an overview of the development history and advantages and disadvantages of measurement methods for soft tissue properties of the plantar foot. The measurement of soft tissue properties is essential for understanding the biomechanical characteristics and function of the foot, as well as for designing and evaluating orthotic devices and footwear. Various methods have been developed to measure the properties of plantar soft tissues, including ultrasound imaging, indentation testing, magnetic resonance elastography, and shear wave elastography. Each method has its own strengths and limitations, and choosing the most appropriate method depends on the specific research or clinical objectives. This review aims to assist researchers and clinicians in selecting the most suitable measurement method for their specific needs.

The impact of diabetes mellitus on foot perfusion measured by ICG NIR fluorescence imaging.

INTRODUCTION: Diabetes Mellitus (DM) is a common chronic disease, affecting 435 million people globally. Impaired vasculature in DM patients leads to complications like lower extremity arterial disease (LEAD) and foot ulcers, often resulting in amputations. DM causes additional peripheral neuropathy leading to multifactorial wound problems. Current diagnostics often deem unreliable, but Near-Infrared Fluorescence with Indocyanine Green (ICG NIR) can be used to assess the foot perfusion. Therefore, this study explores DM's impact on foot perfusion using ICG NIR. METHODS: Baseline ICG NIR fluorescence imaging was performed in LEAD patients with and without DM. Ten perfusion parameters were extracted and analyzed to assess differences in perfusion patterns. RESULTS: Among 109 patients (122 limbs) of the included patients, 32.8 % had DM. Six of ten perfusion parameters, mainly inflow-related, differed significantly between DM and non-DM patients (p-values 0.007-0.039). Fontaine stage 4 DM patients had the highest in- and outflow values, with seven parameters significantly higher (p-values 0.004-0.035). CONCLUSION: DM is associated with increased in- and outflow parameters. Patients with- and without DM should not be compared directly due to different vascular pathophysiology and multifactorial wound problems in DM patients. Quantified ICG NIR fluorescence imaging offers additional insight into the effect of DM on foot perfusion.

[18F]Fluorodeoxyglucose ([18F]FDG) positron emission tomography and conventional imaging modalities in the diagnosis of diabetic foot osteomyelitis: a meta-analysis.

AIM: This meta-analysis aimed to evaluate the comparative diagnostic efficacy of [18F]Fluorodeoxyglucose positron emission tomography ([18F]FDG PET) and conventional imaging, MRI, and white blood cell (WBC) scintigraphy in detecting foot osteomyelitis among diabetic patients. MATERIALS AND METHODS: An exhaustive search was conducted within the PubMed and Embase databases to identify publications available up until February 2024. Studies were included if they evaluated the diagnostic efficacy of [18F]FDG PET or the comparative diagnostic performance between PET and (MRI or WBC scintigraphy). Two researchers independently assessed the quality of the included studies, utilizing the Quality Assessment of Diagnostic Performance Studies (QUADAS-2) tool. RESULTS: Nine retrospective or prospective studies involving 605 patients were included in the meta-analysis. For [18F]FDG PET, the overall sensitivity was 0.83(95% CI: 0.69-0.94), while the overall specificity was 0.92(95% CI: 0.86-0.97). In the head-to-head comparison, no significant difference of sensitivity was found between [18F]FDG PET and MRI (0.72 vs. 0.68, P=0.81), as well as between [18F]FDG PET and WBC scintigraphy (0.57 vs. 0.66, P=0.64). In addition, specificity was also found to be no significant difference between [18F]FDG PET and MRI (0.90 vs. 0.82, P=0.27), as well as [18F]FDG PET and WBC scintigraphy (0.81 vs. 0.93, P=0.09). CONCLUSION: [18F]FDG PET demonstrates similar sensitivity and specificity to MRI and WBC scintigraphy in detecting foot osteomyelitis among diabetic patients. MRI, often cited as a primary choice in guidelines, might be preferred due to its lower cost and lower dose. Further larger sample prospective studies are needed to confirm these findings.

Wearable laser Doppler flowmetry for non-invasive assessment of diabetic foot microcirculation: methodological considerations and clinical implications.

Significance: Type 2 diabetes mellitus (T2DM) is a global health concern with significant implications for vascular health. The current evaluation methods cannot achieve effective, portable, and quantitative evaluation of foot microcirculation. Aim: We aim to use a wearable device laser Doppler flowmetry (LDF) to evaluate the foot microcirculation of T2DM patients at rest. Approach: Eleven T2DM patients and twelve healthy subjects participated in this study. The wearable LDF was used to measure the blood flows (BFs) for regions of the first metatarsal head (M1), fifth metatarsal head (M5), heel, and dorsal foot. Typical wavelet analysis was used to decompose the five individual control mechanisms: endothelial, neurogenic, myogenic, respiratory, and heart components. The mean BF and sample entropy (SE) were calculated, and the differences between diabetic patients and healthy adults and among the four regions were compared. Results: Diabetic patients showed significantly reduced mean BF in the neurogenic (p=0.044) and heart (p=0.001) components at the M1 and M5 regions (p=0.025) compared with healthy adults. Diabetic patients had significantly lower SE in the neurogenic (p=0.049) and myogenic (p=0.032) components at the M1 region, as well as in the endothelial (p<0.001) component at the M5 region and in the myogenic component at the dorsal foot (p=0.007), compared with healthy adults. The SE in the myogenic component at the dorsal foot was lower than at the M5 region (p=0.050) and heel area (p=0.041). Similarly, the SE in the heart component at the dorsal foot was lower than at the M5 region (p=0.017) and heel area (p=0.028) in diabetic patients. Conclusions: This study indicated the potential of using the novel wearable LDF device for tracking vascular complications and implementing targeted interventions in T2DM patients.

Exploring the efficacy of photodynamic antimicrobial chemotherapy on diabetic foot ulcers in rats.

We investigate the efficacy of photodynamic antimicrobial chemotherapy (PACT) and its combination with an antibiotic in the treatment of diabetic foot ulcers (DFUs) in rats using a novel cationic amino acid porphyrin-based photosensitizer. The research findings demonstrate that the combination of novel cationic photosensitizer-mediated PACT and an antibiotic exhibits significant therapeutic efficacy in treating deep ulcers in a rat model of DFUs. Moreover, the PACT + Antibiotic group displays enhanced angiogenesis, improved tissue maturation, and superior wound healing effect. Micro-computed tomography examination showed that the periosteal reaction was most obvious in the PACT + Antibiotic group. The cortical bone volume ratio (BV/TV), the bone mineral density, and trabecular thickness were significantly higher in the PACT + Antibiotic group than in the model group (p < 0.05). The combination of PACT and antibiotic plays a sensitizing therapeutic role, which provides a new idea for the clinical treatment of DFUs.

Multimodal imaging device to comprehensively assess infection, oxygenation, and wound analytics-A pilot study.

Wound analytics, infection detection, and oxygenation measurement are the three critical prerequisites for appropriate wound care. Although devices that rapidly detect the above-mentioned parameters independently exist, there is no single point-of-care device that is enabled with all the three functionalities. Through this study, we are introducing and evaluating the performance of Illuminate Pro Max-a novel, rapid, hand-held non-contact, point-of-care multimodal imaging device that is equipped to measure the three wound assessment parameters. Here, a total of 60 diabetic foot ulcer patients were imaged using Illuminate Pro Max to detect bioburden and measure StO2 levels and wound dimensions (size and depth). The results were further evaluated against the current gold standard technique for each parameter, that is, culture test to detect bioburden, a transcutaneous oxygen pressure (TcPO2) measuring device-Perimed Periflux 5000 to measure oxygenation, and paper ruler to measure wound size. Culture tests reported 42 samples as infection-positive and 18 samples as infection-negative. On comparing with the culture report, the device showed 88% sensitivity and 86% PPV in detecting the bioburden. Wound dimensions (length and width) were comparable with the paper scale measurements. Wound depth was also reported by the device. The StO2 map generated by the device depicted the tissue oxygenation levels in various regions of the wound. In conclusion, this novel, comprehensive point-of-care multispectral imaging device can be an effective tool for rapid wound assessment which can help in prompt treatment.

The usefulness of quantitative 99mTc-HMPAO WBC SPECT/CT for predicting lower extremity amputation in diabetic foot infection.

We investigated the usefulness of quantitative 99mTc-white blood cell (WBC) single photon emission computed tomography (SPECT)/computed tomography (CT) for predicting lower extremity amputation in diabetic foot infection (DFI). A total of 93 feet of 83 consecutive patients with DFI who underwent WBC SPECT/CT for treatment planning were retrospectively analysed. The clinical and SPECT/CT parameters were collected along with the measurements of the maximum standardized uptake value (SUVmax) at DFI. Statistical logistic regression analysis was performed to explore the predictors of LEA and receiver operating characteristic (ROC) curve was analysed to assess the predictive value of SPECT/CT. The independent predictors of amputation were previous amputation (OR 11.9), numbers of SPECT/CT lesions (OR 2.1), and SUVmax of DFI; either continuous SUVmax (1-increase) (OR 1.3) or categorical SUVmax > 1.1 (OR 21.6). However, the conventional SPECT/CT interpretation failed to predict amputation. In ROC analysis, the SUVmax yielded a fair predictor (area under the curve (AUC) 0.782) of amputation. The model developed from these independent predictors yielded an excellent performance for predicting amputation (AUC 0.873). Quantitative WBC SPECT/CT can provide new information useful for predicting the outcomes and guiding treatment for patients with DFI.

Amide proton transfer weighted contrast has diagnostic capacity in detecting diabetic foot: an MRI-based case-control study.

Objective: To evaluate the role of foot muscle amide proton transfer weighted (APTw) contrast and tissue rest perfusion in quantifying diabetic foot (DF) infection and its correlation with blood parameters. Materials and methods: With approval from an ethical review board, this study included 40 diabetes mellitus (DM) patients with DF and 31 DM patients without DF or other lower extremity arterial disease. All subjects underwent MRI, which included foot sagittal APTw and coronal arterial spin labeling (ASL) imaging. The normalized MTRasym (3.5 ppm) and the ratio of blood flow (rBF) in rest status of the affected side lesions to the non-affected contralateral side were determined. The inter-group differences of these variables were evaluated. Furthermore, the association between normalized MTRasym (3.5 ppm), rBF, and blood parameters [fasting blood glucose (FBG), glycosylated hemoglobin content, C-reactive protein, neutrophil percentage, and white blood cell count] was explored. Using an ROC curve, the diagnostic capacity of normalized MTRasym (3.5 ppm), BF, and blood biochemical markers in differentiating with or without DF in DM was assessed. Results: In the DF group, MTRasym (3.5 ppm) and BF in lesion and normalized MTRasym (3.5 ppm) were higher than those in the control group (p < 0.05). In addition, correlations were identified between normalized MTRasym (3.5 ppm) and blood parameters, such as C-reactive protein, glycosylated hemoglobin content, FBG, neutrophil ratio, and white blood cell (p < 0.001). Meanwhile, association between BF in lesion and blood parameters, such as C-reactive protein, neutrophil percentage, and FBG (p < 0.01). AUC of normalized MTRasym (3.5 ppm) in identifying with/without DF in patients with DM is 0.986 (95% CI, 0.918-1.00) with the sensitivity of 97.22% and the specificity of 100%. Conclusion: Normalized MTRasym (3.5 ppm) and the BF in lesion may be treated as a safer and more convenient new indicator to evaluate the tissue infection without using a contrast agent, which may be useful in monitoring and preoperatively assessing DF patients with renal insufficiency.

Diabetic foot ulcers segmentation challenge report: Benchmark and analysis.

Monitoring the healing progress of diabetic foot ulcers is a challenging process. Accurate segmentation of foot ulcers can help podiatrists to quantitatively measure the size of wound regions to assist prediction of healing status. The main challenge in this field is the lack of publicly available manual delineation, which can be time consuming and laborious. Recently, methods based on deep learning have shown excellent results in automatic segmentation of medical images, however, they require large-scale datasets for training, and there is limited consensus on which methods perform the best. The 2022 Diabetic Foot Ulcers segmentation challenge was held in conjunction with the 2022 International Conference on Medical Image Computing and Computer Assisted Intervention, which sought to address these issues and stimulate progress in this research domain. A training set of 2000 images exhibiting diabetic foot ulcers was released with corresponding segmentation ground truth masks. Of the 72 (approved) requests from 47 countries, 26 teams used this data to develop fully automated systems to predict the true segmentation masks on a test set of 2000 images, with the corresponding ground truth segmentation masks kept private. Predictions from participating teams were scored and ranked according to their average Dice similarity coefficient of the ground truth masks and prediction masks. The winning team achieved a Dice of 0.7287 for diabetic foot ulcer segmentation. This challenge has now entered a live leaderboard stage where it serves as a challenging benchmark for diabetic foot ulcer segmentation.

Diagnostic imaging of the diabetic foot: an EANM evidence-based guidance.

PURPOSE: Consensus on the choice of the most accurate imaging strategy in diabetic foot infective and non-infective complications is still lacking. This document provides evidence-based recommendations, aiming at defining which imaging modality should be preferred in different clinical settings. METHODS: This working group includes 8 nuclear medicine physicians appointed by the European Association of Nuclear Medicine (EANM), 3 radiologists and 3 clinicians (one diabetologist, one podiatrist and one infectious diseases specialist) selected for their expertise in diabetic foot. The latter members formulated some clinical questions that are not completely covered by current guidelines. These questions were converted into statements and addressed through a systematic analysis of available literature by using the PICO (Population/Problem-Intervention/Indicator-Comparator-Outcome) strategy. Each consensus statement was scored for level of evidence and for recommendation grade, according to the Oxford Centre for Evidence-Based Medicine (OCEBM) criteria. RESULTS: Nine clinical questions were formulated by clinicians and used to provide 7 evidence-based recommendations: (1) A patient with a positive probe-to-bone test, positive plain X-rays and elevated ESR should be treated for presumptive osteomyelitis (OM). (2) Advanced imaging with MRI and WBC scintigraphy, or [18F]FDG PET/CT, should be considered when it is needed to better evaluate the location, extent or severity of the infection, in order to plan more tailored treatment. (3) In a patient with suspected OM, positive PTB test but negative plain X-rays, advanced imaging with MRI or WBC scintigraphy + SPECT/CT, or with [18F]FDG PET/CT, is needed to accurately assess the extent of the infection. (4) There are no evidence-based data to definitively prefer one imaging modality over the others for detecting OM or STI in fore- mid- and hind-foot. MRI is generally the first advanced imaging modality to be performed. In case of equivocal results, radiolabelled WBC imaging or [18F]FDG PET/CT should be used to detect OM or STI. (5) MRI is the method of choice for diagnosing or excluding Charcot neuro-osteoarthropathy; [18F]FDG PET/CT can be used as an alternative. (6) If assessing whether a patient with a Charcot foot has a superimposed infection, however, WBC scintigraphy may be more accurate than [18F]FDG PET/CT in differentiating OM from Charcot arthropathy. (7) Whenever possible, microbiological or histological assessment should be performed to confirm the diagnosis. (8) Consider appealing to an additional imaging modality in a patient with persisting clinical suspicion of infection, but negative imaging. CONCLUSION: These practical recommendations highlight, and should assist clinicians in understanding, the role of imaging in the diagnostic workup of diabetic foot complications.

BedBiopsy: Diagnostic performance of bedside ultrasound-guided bone biopsies for the management of diabetic foot infection.

OBJECTIVE: We aimed to assess the feasibility and diagnostic performance of ultrasound-guided bone biopsies at the bedside of diabetic patients admitted for suspected foot osteitis not requiring surgery. RESEARCH DESIGN AND METHODS: In this retrospective monocentric study, we compared the performance of ultrasound-guided (n = 29 consecutive patients, Dec.2020-Oct.2022) versus surgical (n = 24 consecutive patients, Jan.2018-Nov.2020) bone biopsies at confirming or ruling out diabetic foot osteitis (primary outcome). RESULTS: Patient characteristics were similar in the two intervention groups, including arteritis prevalence (62.3 %), SINBAD score, and wound location (phalanges 36 %, metatarsus 43 %, and calcaneus 21 %). However, the ultrasound-guided group was older (67 ± 11 versus 60 ± 13 years respectively, P = 0.047) and had more type 2 diabetes (97 % versus 75 %, P = 0.038). Diagnostic performance (i.e., capacity to confirm or rule out suspected osteitis) was similar for ultrasound-guided (28/29 cases: 25 confirmations, 3 invalidations) and surgical (24 confirmations/24) biopsies, P = 0.358. No biopsy-related side effect or complication was observed for either intervention, even for patients on antiaggregation and/or anticoagulation therapy. The mean (± standard deviation) time necessary to perform the biopsy was shorter in the ultrasound-guided group (2.6 ± 3.0 versus 7.2 ± 5.8 days, respectively, P < 0.001) and wound evolution at three months was more favorable (83.3 versus 41.2 %, P = 0.005) (94.4 % versus 66.7 %, respectively, patients with new surgical procedure within six months excluded; P = 0.055). Even though not statistically significant, healing rates in terms of wound and osteitis at six months were also better in the ultrasound-guided group (wound: 40.9 % versus 36.8 %; P = 0.790, and osteitis: 81.8 vs 55.6 % P = 0.071). CONCLUSION: In diabetic patients with suspected foot osteitis not requiring surgery, bedside ultrasound-guided bone biopsies may constitute a promising alternative to surgical biopsies. This intervention provided excellent tolerance and microbiological documentation, short lead-times, and more favorable wound prognosis.

The role of diabetic foot treatment in improving left ventricular function: Insights from global longitudinal strain echocardiography.

We decided to evaluate the effect of treatment of diabetic foot ulcers in improving heart function by strain echocardiography than conventional transthoracic echocardiography. This prospective cross-sectional study included patients with diabetic foot ulcer (DFU). Conventional and two-dimensional strain echocardiography performed before and after three months diabetic foot treatment. Then, we compared the echocardiographic parameters including left ventricular ejection fraction (LV-EF), left ventricular global longitudinal strain (LV-GLS). Multivariate and univariate logistic regression analysis were performed to find which variable was mainly associated with LV-GLS changes. 62 patients with DFU were conducted. After echocardiography, all patients underwent surgical or non-surgical treatments. Three months after the treatment, LV-EF was not significantly different with its' primary values (P = 0.250), but LV-GLS became significantly different (P<0.05). In the multivariate logistic regression analysis, with the increase in the grade of ulcer, LV-GLS improved by 6.3 times. Not only the treatment of DFU helps to control adverse outcomes like infection, limb loss and morbidity but also it enhances cardiac function. Of note, strain echocardiography found to be a better indicator of myocardial dysfunction than LV-EF. These findings make a strong reason for the routine assessment of cardiac function in patients with DFU.

Image Smart Segmentation Analysis Against Diabetic Foot Ulcer Using Internet of Things with Virtual Sensing.

Diabetic foot ulcer (DFU) is a problem worldwide, and prevention is crucial. The image segmentation analysis of DFU identification plays a significant role. This will produce different segmentation of the same idea, incomplete, imprecise, and other problems. To address these issues, a method of image segmentation analysis of DFU through internet of things with the technique of virtual sensing for semantically similar objects, the analysis of four levels of range segmentation (region-based, edge-based, image-based, and computer-aided design-based range segmentation) for deeper segmentation of images is implemented. In this study, the multimodal is compressed with the object co-segmentation for semantical segmentation. The result is predicting the better validity and reliability assessment. The experimental results demonstrate that the proposed model can efficiently perform segmentation analysis, with a lower error rate, than the existing methodologies. The findings on the multiple-image dataset show that DFU obtains an average segmentation score of 90.85% and 89.03% correspondingly in two types of labeled ratios before DFU with virtual sensing and after DFU without virtual sensing (i.e., 25% and 30%), which is an increase of 10.91% and 12.22% over the previous best results. In live DFU studies, our proposed system improved by 59.1% compared with existing deep segmentation-based techniques and its average image smart segmentation improvements over its contemporaries are 15.06%, 23.94%, and 45.41%, respectively. Proposed range-based segmentation achieves interobserver reliability by 73.9% on the positive test namely likelihood ratio test set with only a 0.25 million parameters at the pace of labeled data.

Diagnostic Performance of Ultrasonography for Diabetic Foot Osteomyelitis.

Objective: This study aims to analyze the potential diagnostic capability of ultrasonography (US) in detecting diabetic foot osteomyelitis (DFO) in patients with diabetic foot ulcers (DFUs). Approach: A 1-year prospective study was conducted on 47 consecutive patients with active DFUs and suspicion of DFO at a specialized diabetic foot unit. The following ultrasonographic features were evaluated at baseline: (1) periosteal reaction; (2) periosteal elevation; (3) cortical disruption; (4) sequestrum; and (5) positive power Doppler. The primary outcome measure aimed to establish the effectiveness of ultrasonographic features compared with aseptic bone culture for diagnosing DFO. Receiver operating characteristic (ROC) curves were utilized to evaluate the diagnostic performance of ultrasonographic features. Sample size could not be determined as it is the first study to assess ultrasonographic features for the diagnosis of DFO. The research adhered to the guidelines for diagnostic accuracy studies (Standards for Reporting of Diagnostic Accuracy Studies [STARD] 2015). Results: All patients (n = 24) diagnosed with DFO exhibited positive power Doppler, resulting in a sensitivity (S) and specificity (SP) of 1 and an area under the curve (AUC) of 1 (p < 0.001 [1-1]). Cortical disruption was present in 23 patients (95.8%) with DFO, yielding an S of 0.93, SP of 1, and AUC of 0.96 (p < 0.001 [0.88-1]). Innovation: It validates the diagnostic value of US for DFO as it is the first and largest study of its kind to establish a clear reference standard to guide clinician decision-making. Conclusion: This study demonstrates the effectiveness of cortical disruption and positive power Doppler in assessing DFO through US.

Feasibility of Multiparametric Perfusion Assessment in Diabetic Foot Ulcer Using Intravoxel Incoherent Motion and Blood Oxygenation-Level Dependent MRI.

BACKGROUND: Patients with type-2 diabetes (T2DM) are at increased risk of developing diabetic foot ulcers (DFU) and experiencing impaired wound healing related to underlying microvascular disease. PURPOSE: To evaluate the sensitivity of intra-voxel incoherent motion (IVIM) and blood oxygen level dependent (BOLD) MRI to microvascular changes in patients with DFUs. STUDY TYPE: Case-control. POPULATION: 20 volunteers who were age and body mass index matched, including T2DM patients with DFUs (N = 10, mean age = 57.5 years), T2DM patients with controlled glycemia and without DFUs (DC, N = 5, mean age = 57.4 years) and healthy controls (HC, N = 5, mean age = 52.8 years). FIELD STRENGTH/SEQUENCE: 3T/multi-b-value IVIM and dynamic BOLD. ASSESSMENT: Resting IVIM parameters were obtained using a multi-b-value diffusion-weighted imaging sequence and two IVIM models were fit to obtain diffusion coefficient (D), pseudo-diffusion coefficient (D*), perfusion fraction (f) and microvascular volume fraction (MVF) parameters. Microvascular reactivity was evaluated by inducing an ischemic state in the foot with a blood pressure cuff during dynamic BOLD imaging. Perfusion indices were assessed in two regions of the foot: the medial plantar (MP) and lateral plantar (LP) regions. STATISTICAL TESTS: Effect sizes of group mean differences were assessed using Hedge's g adjusted for small sample sizes. RESULTS: DFU participants exhibited elevated D*, f, and MVF values in both regions (g ≥ 1.10) and increased D (g = 1.07) in the MP region compared to DC participants. DC participants showed reduced f and MVF compared to HC participants in the MP region (g ≥ 1.06). Finally, the DFU group showed reduced tolerance for ischemia in the LP region (g = -1.51) and blunted reperfusion response in both regions (g < -2.32) compared to the DC group during the cuff-occlusion challenge. DATA CONCLUSION: The combined use of IVIM and BOLD MRI shows promise in differentiating perfusion abnormalities in the feet of diabetic patients and suggests hyperperfusion in DFU patients. LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY: Stage 1.

Improved small vessel visibility in diabetic foot arteriography using dual-energy CT.

AIM: To test the feasibility and performance of dual-energy computed tomography (DECT) in foot arteriography of diabetic patients, where contrast medium is largely reduced within the small vessels. MATERIALS AND METHODS: A total of 50 diabetic patients were enrolled prospectively, where DECT was acquired immediately after the CT angiography (CTA, group A) of the lower extremity. Two images were derived from the DECT data, one optimal virtual monochromatic image (VMI, group B) and one fusion image (group C), both of which were compared against the CTA image for visualising the foot arteries. The contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) were evaluated. The arterial course and contrast were graded each using a five-point scale. The clarity of small vessel depiction was quantified by comparing the number of plantar metatarsal arteries found in the maximum intensity projection image. RESULTS: The median CNRs and SNRs obtained in group B were approximately 45% and 20% higher than those in groups A and C, respectively (p<0.05). Group B also received higher subjective scores on the posterior tibial artery and the foot arteries (all >3) than groups A and C. The number of visible branches of the plantar metatarsal arteries was found to be substantially higher (p<0.05) in group B (median=6) than in groups A (median=2) and C (median=4). CONCLUSION: DECT was found to be superior to conventional CTA in foot arteriography, and beyond the lower extremity, it might be a general favourable solution for imaging regions with small vessels and reduced contrast medium.