Radiological diagnosis of prevalent osteoporotic vertebral fracture on radiographs: an interim consensus from a group of experts of the ESSR osteoporosis and metabolism subcommittee.

When a low-energy trauma induces an acute vertebral fracture (VF) with clinical symptoms, a definitive diagnosis of osteoporotic vertebral fracture (OVF) can be made. Beyond that, a "gold" radiographic standard to distinguish osteoporotic from non-osteoporotic VFs does not exist. Fracture-shaped vertebral deformity (FSVD) is defined as a deformity radiographically indistinguishable from vertebral fracture according to the best of the reading radiologist's knowledge. FSVD is not uncommon among young populations with normal bone strength. FSVD among an older population is called osteoporotic-like vertebral fracture (OLVF) when the FSVD is likely to be associated with compromised bone strength. In more severe grade deformities or when a vertebra is collapsed, OVF diagnosis can be made with a relatively high degree of certainty by experienced readers. In "milder" cases, OVF is often diagnosed based on a high probability rather than an absolute diagnosis. After excluding known mimickers, singular vertebral wedging in older women is statistically most likely an OLVF. For older women, three non-adjacent minimal grade OLVF (< 20% height loss), one minimal grade OLVF and one mild OLVF (20-25% height loss), or one OLVF with ≥ 25% height loss, meet the diagnosis of osteoporosis. For older men, a single OLVF with < 40% height loss may be insufficient to suggest the subject is osteoporotic. Common OLVF differential diagnoses include X-ray projection artifacts and scoliosis, acquired and developmental short vertebrae, osteoarthritic wedging, oncological deformities, deformity due to high-energy trauma VF, lateral hyperosteogeny of a vertebral body, Cupid's bow, and expansive endplate, among others.

Multilevel Annotation of Germline MEN1 Variants of Synonymous, Nonsynonymous, and Uncertain Significance in Indian Patients With Sporadic Primary Hyperparathyroidism.

Primary hyperparathyroidism (PHPT) is third most common endocrine disorder characterized by hypercalcemia with elevated or nonsuppressed parathyroid hormone levels by parathyroid tumors. Familial PHPT, as part of multiple endocrine type-1, occurs due to the germline mutation in the MEN1 gene. The involvement and the role of germline MEN1 variations in sporadic PHPT of Indian PHPT patients are unknown. Precise classifications of different types of MEN1 variations are fundamental for determining clinical relevance and diagnostic role. This prospective cohort study was performed on 82 patients with PHPT (with no clinical or history of MEN1) who underwent screening for MEN1 variations through Sanger sequencing. Multilevel computational analysis was performed to determine the structure-function relationship of synonymous, nonsynonymous, and variants of uncertain significance (VUS). Of the 82 PHPT patients, 42 (51%) had 26 germline MEN1 variants, including eight nonsynonymous, seven synonymous, nine VUS, one splice site, and one regulatory variation. Five most common germline variations (c.1838A>G, c.1817C>T, c.1525C>A, c.-35A>T, and c.250T>C) were observed in this study. c.-35A>T (5' untranslated region [UTR]) was associated with recurrence of PHPT (odds ratio [OR] = 5.4; p = 0.04) and subsequent detection of other endocrine tumors (OR = 13.6, p = 0.035). c.1525C>A was associated with multi glandular parathyroid tumor (OR = 13.6, p = 0.035). Align-Grantham variation and Grantham deviation (Align-GVGD), functional analysis through hidden Markov MODEL (FATHMM), and MutationTaster analysis reported the disease-specific potential of VUS and synonymous variations. Significant linkage disequilibrium was observed in c.1785G>A and c.1817C>T (r2  = 0.3859, p = 0.0001), c.1475C>G and c.1525C>A (r2  = 0.385, p = 0.0004), and c.1569T>C and c.1838A>G (r2  = 0.488, p = 0.0001). The detection of MEN1 variations, especially those with disease-specific potential, can prompt early screening for other MEN1-related tumors and disease recurrence. © 2022 American Society for Bone and Mineral Research (ASBMR).

The role of diffusion-weighted imaging and dynamic contrast-enhanced magnetic resonance imaging for the diagnosis of diabetic foot osteomyelitis: a preliminary report.

Purpose: To assess the role of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and diffusionweighted imaging (DWI) in diagnosing diabetic foot osteomyelitis (DFO). Material and methods: Twenty-five participants with suspected osteomyelitis were included, who underwent MRI including DCE-MRI and DWI sequences. It was subsequently followed by bone biopsy and microbiological analysis (gold standard). The participants were divided into 2 groups based on biopsy results: DFO-positive or DFO-negative. The semi-quantitative DCE-MRI parameters (SI0, SImax, SIrel, wash-in rate [WIR], and type of curve) and apparent diffusion coefficient (ADC) values were subsequently compared between the 2 groups. Results: Out of the 25 cases, 19 were DFO-positive and 6 were DFO-negative on bone biopsy. The SI0, SImax, and WIR were significantly higher in DFO-positive cases (p-value 0.050, 0.023, and 0.004, respectively). No difference was seen in SIrel. 100% negative cases revealed type-I curve, and 94% of positive cases showed type-II curve. SI0 > 143.4 revealed a sensitivity of 94.7% and specificity of 83.3%. SImax had a sensitivity of 89.5% but lower specificity of 67.7% at a cut-off value of 408.35. The most significant difference was seen with WIR; p-value ~0.004. At the cut-off value of > 1.280, it had a specificity and sensitivity of 100% and 76%, respectively. Also, ADC values below 1.57 × 10-3 had a sensitivity of 88.2% and specificity of 80% for diagnosing DFO. Conclusions: DWI and DCE-MRI provide non-invasive sequences, which can help to increase the overall specificity and sensitivity of conventional MRI for the diagnosis of osteomyelitis, differentiating it from acute Charcot's arthropathy.

Camurati-Engelmann Disease Complicated by Hypopituitarism: Management Challenges and Literature Review of Outcomes With Bisphosphonates.

Background: Camurati-Engelmann disease (CED) is a rare bone dysplasia characterized by diffuse diaphyseal osteosclerosis. Skull base involvement in CED can result in hypopituitarism but is seldom reported. Our objective was to report a patient with acquired hypopituitarism due to CED and assess the management challenges. Case Report: A 20-year-old boy presented with lower limb pain. He had walking difficulty in childhood, which was diagnosed as CED and managed with prednisolone. He later discontinued treatment and was lost to follow-up. Current re-evaluation showed short stature (-3.6 standard deviation), low weight (-4.3 standard deviation), and delayed puberty with delayed bone age (13 years). He was found to have secondary hypogonadism (luteinizing hormone level, 0.1 mIU/mL [1.7-8.6 mIU/mL]; follicle-stimulating hormone level, 1.0 mIU/mL [1.5-12.4 mIU/mL]; and testosterone level, 0.087 nmol/L [9-27 nmol/L]), growth hormone deficiency (low insulin-like growth factor I level, 120 ng/mL [226-903 ng/mL] and peak growth hormone level of 7 ng/mL on insulin-induced hypoglycemia), and secondary hypocortisolism (cortisol level, 105 nmol/L [170-550 nmol/L] and adrenocorticotropic hormone level, 6 pg/mL [5-65 pg/mL]). Serum prolactin level was normal (8.3 ng/mL [5-20 ng/mL]), and he was euthyroid on levothyroxine replacement. Magnetic resonance imaging revealed a partially empty sella. Sanger sequencing revealed a missense mutation (p.R218C/c.652C>T) in exon 4 of the TGFß1 gene. The patient was treated with zoledronate, losartan, and oral prednisolone and continued on levothyroxine and testosterone replacement, which resulted in symptomatic improvement. Discussion: The index case manifested severe CED requiring multimodality therapy. Later, he developed combined pituitary hormone deficiencies, which were managed with thyroid and gonadal hormone replacement with the continuation of glucocorticoids. The partial efficacy of bisphosphonates in CED has been reported in the literature. Conclusion: Skull base involvement in CED can lead to structural and functional hypopituitarism as a result of intracranial hypertension.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part VII, nerves of the lower limb.

OBJECTIVES: To perform a Delphi-based consensus on published evidence on image-guided interventional procedures for peripheral nerves of the lower limb (excluding Morton's neuroma) and provide clinical indications. METHODS: We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around peripheral nerves in the lower limb (excluding Morton's neuroma) to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper. RESULTS: Nine statements on image-guided interventional procedures for peripheral nerves of the lower limb have been drafted. All of them received strong consensus. Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications. US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role. US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia. CONCLUSION: Despite the promising results reported by published papers on image-guided interventional procedures for peripheral nerves of the lower limb, there is still a lack of evidence on the efficacy of most procedures. KEY POINTS: • Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications. • US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role. • US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia. The volume of local anesthetic affects the size of the blocked sensory area.

Outcomes of plate osteosynthesis for displaced 3-part and 4-part proximal humerus fractures with deltopectoral vs. deltoid split approach.

PURPOSE: Three part and four-part fractures of the proximal humerus offer challenges in reduction and plate fixation, with considerable debate about use of Deltoid splitting (DS) and Delto-pectoral (DP) approaches, especially when they involving the greater tuberosity. We prospectively compared the results using DS approach and DP approach in these cases, with special focus on functional outcomes, complications, and ease of tuberosity reduction. MATERIALS AND METHODS: 84 patients with three- and four-part proximal humerus fracture were alternately allocated the DP approach or DS approach for proximal humerus locking plate fixation. The outcome analysis was done by evaluating relative Constant score and ease of surgical reduction of greater tuberosity; radiological malunion was evaluated using Beredjiklian classification and complications were noted. RESULTS: At mean follow-up of 23 months (19-48 months), the mean 'relative Constant score was 74.27 ± 8.19 in the DP group and 73.26 ± 8.02 in the DS group and the difference was statistically insignificant (p = 0.988). There was no significant difference with respect to shoulder ROM, abductor strength, radiological malunion or complications. However, the mean surgical time was significantly less (p value = 0.042) in DS group (65 ± 5 min) in comparison to DP group (92 ± 4.3 min); significantly less difficulties were documented by the surgeon in reducing the greater tuberosity in DS group(p value = 0.02). CONCLUSION: Although surgical time was reduced and greater tuberosity reduction was easier in DS group, the other outcomes were similar; either surgical approach can be used based, and can be based on the experience and comfort level of the surgeon.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part VI, foot and ankle.

OBJECTIVES: Clarity regarding accuracy and effectiveness for interventional procedures around the foot and ankle is lacking. Consequently, a board of 53 members of the Ultrasound and Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) reviewed the published literature to evaluate the evidence on image-guided musculoskeletal interventional procedures around this anatomical region. METHODS: We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around foot and ankle in order to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper that was shared with all panel members for final approval. RESULTS: A list of 16 evidence-based statements on clinical indications for image-guided musculoskeletal interventional procedures in the foot and ankle were drafted after a literature review. The highest level of evidence was reported for four statements, all receiving 100% agreement. CONCLUSION: According to this consensus, image-guided interventions should not be considered a first-level approach for treating Achilles tendinopathy, while ultrasonography guidance is strongly recommended to improve the efficacy of interventional procedures for plantar fasciitis and Morton's neuroma, particularly using platelet-rich plasma and corticosteroids, respectively. KEY POINTS: • The expert panel of the ESSR listed 16 evidence-based statements on clinical indications of image-guided musculoskeletal interventional procedures in the foot and ankle. • Strong consensus was obtained for all statements. • The highest level of evidence was reached by four statements concerning the effectiveness of US-guided injections of corticosteroid for Morton's neuroma and PRP for plantar fasciitis.

Baseline renal dysfunction determines mortality following parathyroidectomy in primary hyperparathyroidism: analysis of Indian PHPT registry.

INTRODUCTION: Primary hyperparathyroidism (PHPT) in India is mostly symptomatic with renal and skeletal complications. Evidence on mortality outcomes following parathyroidectomy from India, where the disease is predominantly symptomatic is limited. MATERIAL AND METHODS: This was a prospective study to evaluate mortality outcomes in the Indian PHPT registry over the past 25 years (n = 464). Pre- and postoperative parameters and mortality data were obtained from medical records and/or by verbal autopsy, a method validated by WHO for data collection in settings where several deaths are noninstitutional. Patients were divided into survivor (SG) and nonsurvivor groups (NSG) to ascertain differences in presentation and the effect of parathyroidectomy. RESULTS: The overall mortality was 8.8% at a median follow-up of 8 years (IQR 1-13) after parathyroidectomy. Chronic kidney disease was the most common background cause of death (43.5%), followed by pancreatitis (28.2%). NSG had significantly more frequent renal dysfunction (91.9% vs 73.9%), anaemia (50 vs 16.6%) and pancreatitis (24.3 vs 6.4%). PTH (61.9 vs 38.3 pmol/l) and baseline creatinine (97.2 vs 70.7 µmol/l) were significantly higher and eGFR lower (66.7 vs 90.7 ml/min/1.73m2) in the NSG than SG. By Cox proportional modelling, renal dysfunction [HR 2.88 (1.42-5.84)], anaemia [HR 2.45 (1.11-5.42)] and pancreatitis [HR 2.65 (1.24-5.66)] on univariate and renal dysfunction [HR 3.33 (1.13-9.77)] on multivariate analysis were significant for mortality. Survival curves demonstrated a significantly higher mortality with lower eGFR values. CONCLUSIONS: Nonsurvivors in PHPT had greater prevalence and more severe baseline renal dysfunction than survivors. Survival after parathyroidectomy was significantly associated with estimated glomerular filtration rate at baseline.

Primary elbow osteoarthritis presenting as ulnar nerve palsy with claw hand.

A 59-year-old woman was referred with weakness, paraesthesia, numbness and clawing of the little and ring fingers for the last 2 years. MRI of the cervical spine was normal and nerve conduction velocity revealed abnormality of the ulnar nerve. Ultrasound and MRI showed medial osteophytes and effusion of the elbow joint with stretched and thinned ulnar nerve in the cubital tunnel. The patient underwent release and anterior transposition of the ulnar nerve with significant relief of symptoms.

Eumycetoma of the Foot due to Fusarium solani in a Person with Diabetes Mellitus: Report of a Case and Review of Literature.

Eumycetomas are chronic suppurative granulomas caused by fungi characterised by invasive tumefactive lesions, sinuses and discharging grains. Herein, we describe a case of pedal eumycetoma due to Fusarium solani sensu stricto in a person with diabetes mellitus. A 45-year-old gentleman presented with an insidious onset swelling over his right foot with nodules and discharging grains. He had received itraconazole and anti-tuberculous therapy elsewhere, without response. Re-evaluation included a biopsy which confirmed eumycetoma and newly diagnosed diabetes. Surgical excision followed by histopathological, microbiological and multigene sequencing analyses [translation elongation factor, calmodulin and internal transcribed spacer region of rDNA] of the mould on culture were performed. Histopathology revealed septate fungal hyphae amidst a dense inflammatory infiltrate (Splendore-Hoeppli) reaction. Oral voriconazole was started and good glycemic control attained. Tissue growth sequences showed > 99% similarity with Fusarium solani sensu stricto. Antifungal susceptibility testing showed lowest MIC to voriconazole (0.5 mg/L). The patient showed excellent response to combined therapeutic modality with a near-complete resolution in size of lesion and obliteration of sinuses following 4 months of therapy and is planned for prolonged voriconazole therapy till complete radiological resolution. Diabetes predisposes to fungal infections of foot but eumycetomas are uncommon. Combined surgery and antifungals can improve morbidity and avoid amputations.

Patellar Osteoid Osteoma as a Cause of Intractable Anterior Knee Pain - A Case Report and Systematic Review of Literature.

INTRODUCTION: Patellar involvement by osteoid osteoma is very rare. Osteoid osteomas that present as anterior knee pain are frequently misdiagnosed which leads to initial delay in treatment. Plain radiology has poor diagnostic yield. A combination of high index of suspicion, appropriate imaging, and complete ablation of the lesion is necessary to achieve good outcomes. CASE REPORT: A 16-year-old male presented with insidious onset anterior knee pain for the past 2 years. The pain was intermittent and mild; however, it increased progressively in intensity and frequency, which was worse at night. Examination reveals minimal effusion in the suprapatellar pouch, full range of motion of the knee, and wasting of the quadriceps. Serum biochemistry parameters were in normal limits. Plain radiographs did not reveal any significant abnormality. On magnetic resonance imaging, a hypointense, punctate lesion surrounded by a small hyperintense zone was noted at medial aspect of patella. A computed tomography scan showed the lesion with a central nidus, surrounded by a sclerotic rim, confirming the diagnosis of osteoid osteoma. Radiofrequency ablation was carried out without any post-procedural complications. The patient was pain free a few days after the procedure. At 14-month follow-up, there was no recurrence of symptoms. CONCLUSION: Osteoid osteomas that present as anterior knee pain are frequently misdiagnosed. Plain radiology has poor diagnostic yield. A combination of high index of suspicion, appropriate imaging, and complete ablation of the lesion is necessary to achieve good outcomes.

Innocuous "foot lump" in patient with diabetes mellitus: A manifestation of phaeohyphomycosis.

Invasive mycotic infection presenting as "foot lump" in an immunocompetent patient is extremely rare. The case highlights the difficulty in diagnosis of fungal infections of foot including attempts to isolate the fungus and non-response to anti-fungal agents. A 64-year-old lady with T2DM for four years presented with painless, gradually progressive swelling over plantar aspect of left mid-foot for six months. Foot examination revealed soft-to-firm lump over the plantar aspect of left mid-foot obscuring the lateral longitudinal arch. No signs of inflammation or bony deformities were noticed. X-ray foot revealed radio-dense shadow in soft tissue without bone changes, corroborated by MRI. A diagnosis of lipoma, ganglion cyst, tubercular abscess and a fungal infection were considered. Aspirate cytology suggested the presence of Aspergillus hyphae although repeated cultures were unsuccessful. Medical management in form of itraconazole initially, followed by voriconazole was tried. However, there was no response to anti fungal agents and the lesion was surgically excised. Histopathological examination confirmed the presence of pigmented fungus (phaehyphomycosis).

Clinical features and long-term outcomes of 105 granulomatosis with polyangiitis patients: A single center experience from north India.

AIM: To describe the clinical features, treatment and long-term outcomes in north Indian patients with granulomatosis with polyangiitis (GPA). METHODS: Clinical details, Birmingham Vasculitis Activity Score (BVAS-v3), laboratory data, histopathology findings, treatment details and outcomes of all consecutive patients diagnosed as having GPA between April 2005 and April 2016 were retrieved. European Vasculitis Study Group definitions were used to classify patients into localized, early systemic, generalized, severe and refractory categories. The findings were compared with large single center cohorts from USA, Germany and France. RESULTS: One hundred and five patients (median age 40 years; 60 females and 45 males) were diagnosed as having GPA. Median duration of follow up was 28 months. Upper respiratory tract, renal and lung involvement were seen in 76.19%, 51.43% and 67.62% of patients, respectively. Ocular, ear, central nervous system, peripheral nervous system, heart, gastrointestinal and skin involvement were seen in 40.95%, 18.1%, 26.67%, 11.43%, 5.71%, 12.38% and 29.52%, respectively. The median BVAS v3 score was 17. Localized, early systemic, generalized, severe and refractory disease were seen in three, 44, 38, 17 and one patient, respectively. Eighteen patients expired and the cause of death was disease activity in 11, disease activity plus sepsis in four and sepsis alone in three patients. Twenty-six patients experienced relapses. No hemorrhagic cystitis or bladder cancers were observed; however, one patient developed myelodysplastic syndrome during follow up. CONCLUSION: Indian patients are younger and have less arthritis, renal and peripheral nerve involvement as compared to the patients in Western cohorts.

Frequency & predictors of pancreatitis in symptomatic primary hyperparathyroidism.

BACKGROUND & OBJECTIVES: The frequency and predictors of pancreatitis in primary hyperparathyroidism (PHPT) are not well understood. The objective of the present study was to evaluate the frequency of pancreatitis in patients with PHPT and its association with clinical and biochemical parameters of the disease. METHODS: In this retrospective study all consecutive patients with PHPT registered in the PHPT registry (www.indianphptregistry.com) from the year 2004 to 2013 were included. The clinical, biochemical and radiological parameters related to pancreatitis were evaluated in histologically proven PHPT patients. RESULTS: A total of 218 patients (63 men; mean age: 40.6±14.4 yr) underwent surgery for PHPT during the study. Pancreatitis occurred in 35 [16%, 18 acute and 17 chronic pancreatitis (CP)] patients and male:female ratio was 1:0.94. Skeletal manifestations were seen less frequently in PHPT with pancreatitis as compared to that of PHPT without pancreatitis. PHPT with pancreatitis had significantly higher serum calcium (12.4±2.0 vs. 11.7±1.5 mg/dl, P <0.05) in comparison to PHPT without pancreatitis. PHPT with acute pancreatitis (AP) had higher serum calcium (P <0.05) and parathyroid hormone (PTH) (P <0.05) levels than PHPT with CP. Curative parathyroidectomy improved the symptoms associated with pancreatitis as there was no recurrence in AP group, whereas recurrence was observed only in about 10 per cent patients of the CP group. INTERPRETATION & CONCLUSIONS: Pancreatitis was observed in 16 per cent of PHPT patients with male predominance in the study population. No recurrence of AP was observed after curative surgery. It may be proposed that serum amylase with calcium and PTH should be measured in all patients of PHPT with pain abdomen to rule out pancreatitis.

Radiological manifestations of hydatid disease and its complications.

Hydatid disease (HD) is endemic in many parts of the world. HD can affect virtually any organ system in body and should be kept as differential diagnosis of cystic lesion. HD is mostly asymptomatic; however, it demonstrates a variety of characteristic imaging findings depending on the site of involvement, stage of growth, mass effect, complications, or hematogenous spread, which helps in diagnosis. Radiography, ultrasonography (USG), computed tomography (CT), and magnetic resonance imaging (MRI) are commonly used imaging modalities. Radiography is helpful in chest and for demonstrating calcification. USG demonstrates characteristic findings such as cystic nature, daughter vesicles, membranes, septa, and hydatid sand. CT and MRI are modalities of choice for number, size, anatomic location, identification of local complications, and systemic spread. CT is, especially helpful for osseous involvement, and MRI is better for biliary and neurological involvement. Knowledge of these imaging findings helps in early diagnosis and timely initiation of appropriate therapy.

Utility of PET/CT with fluorine-18-fluorodeoxyglucose-labeled autologous leukocytes for diagnosing diabetic foot osteomyelitis in patients with Charcot's neuroarthropathy.

OBJECTIVE: Diabetic foot osteomyelitis (DFO) is difficult to diagnose in the presence of Charcot's neuroarthropathy (CN) and bone biopsy is not always possible. We aimed to assess the efficacy of PET/computed tomography using F-fluoride (F-fluoride PET/CT) and fluorine-18-fluorodeoxyglucose-labeled autologous leukocytes (F-FDG-LL PET/CT) in comparison with contrast-enhanced MRI (CEMRI) for the detection of DFO. PATIENTS AND METHODS: Thirty-two patients with chronic CN and foot ulcer suspected of having DFO were prospectively evaluated. All patients underwent radiography, CEMRI, F-fluoride PET/CT, and F-FDG-LL PET/CT of the feet. Bone biopsy and microbiological culture from the suspected site of osteomyelitis was considered the gold standard. RESULTS: Twenty-three patients fulfilled the inclusion criteria. Bone culture was suggestive of DFO in 12 patients. CEMRI identified 10 of the 12 cases of osteomyelitis. F-fluoride PET/CT and F-FDG-LL PET/CT showed increased tracer uptake (SUVmax=22.7±18.1 and 8.4±4.7, respectively) at the clinically involved site in 10 of the 12 patients (TP). Among 11 biopsy-negative patients, CEMRI reported DFO in four (false positive); there were no false positives with F-FDG-LL PET/CT. The sensitivity and specificity of F-FDG-LL PET/CT was 83.3 and 100% compared with 83.3 and 63.6% for CEMRI, respectively, for the diagnosis of DFO in the background of CN. CONCLUSION: F-FDG-LL PET/CT has high specificity for the diagnosis of DFO in complicated diabetic foot. The F-fluoride PET/CT helps in the characterization the extent of underlying CN. An early and accurate diagnosis with F-FDG-LL PET/CT aids the rational initiation of antibiotics for DFO.

Osteofibrous dysplasia of clavicle clinically mimicking chronic osteomyelitis.

Osteofibrous dysplasia or ossifying fibroma is an uncommon benign fibro-osseous lesion of childhood, commonly described in the maxilla and the mandible. Among long bones, it usually presents in the tibia as a painless swelling or anterior bowing. Ossifying fibroma of clavicle has never been reported in English literature, to the best of our knowledge. Here, we would like to present an unusual case of osteofibrous dysplasia of clavicle clinically mimicking chronic osteomyelitis.