The diagnostic value of single photon-emission computed tomography bone scans combined with CT (SPECT-CT) in diseases of the foot and ankle

BackgroundA radionuclide bone scan with single photon-emission computed tomography and CT (SPECT-CT) is a new imaging modality which combines highly detailed CT with the functional information from a triple phase radionuclide bone scan. Little has been published about its diagnostic accuracy and usefulness in foot and ankle pathology. The aim of this study is to evaluate whether bone scans with SPECT-CT provide a useful contribution to the management of patients with foot and ankle pain, and whether it results in changes to clinical management.MethodsA retrospective study involving 50 patients was conducted between March 2010 and April 2011. SPECT-CT was requested in cases where definitive clinical diagnosis could not be achieved after clinical examination and plain radiography. Pathology as highlighted on SPECT-CT was taken as the definitive diagnosis in these patients and was treated accordingly. Patients were subsequently seen in the follow up clinic to evaluate the outcome of their treatment.ResultsIn 11 patients (22%), the provisional clinical diagnosis matched with the findings of the SPECT-CT and no change in treatment was necessary. In 39 patients (78%) the findings of the SPECT-CT did not correlate exactly with the initial clinical diagnosis and led to a modified treatment plan. The accuracy, sensitivity, specificity, positive predictive and negative predictive value of SPECT-CT in this series was 94%, 95.45%, 83.3%, 97.6% and 71.43% respectively.ConclusionsSPECT-CT is a useful investigation tool in foot and ankle pathologies. The present study shows a high diagnostic accuracy and we recommend its use in cases with diagnostic uncertainty.     

Prevalence of Painful Peroneal Tubercles in the Pediatric Population

Pain isolated to the lateral aspect of the heel can be difficult to diagnose, particularly in the growing child. Peroneal tendinopathy or frank tears of the peroneal tendons secondary to an enlarged peroneal tubercle has been implicated as a potential source of pain in adults. Neither the prevalence of enlarged peroneal tubercles in the pediatric population nor the number of symptomatic tubercles in children has been elucidated. We conducted a review of children who presented to our institution with foot and/or ankle pain and who underwent 3-dimensional computed tomography. Initially, a radiographic review was undertaken of all computed tomography scans to determine the prevalence of peroneal tubercles in children. The peroneal tubercles were measured and then classified according to height. The children with tubercles 3 mm or greater in height (adult mean height) underwent a more detailed chart review to evaluate for the incidence of painful tubercles. During the study period, 2,689 children were seen for foot and ankle pain, and 367 underwent a computed tomography scan during their treatment course. Of these 367 patients, 57% had a measurable peroneal tubercle, and 162 (44%) met the criteria for chart review. Only 3 adolescents (1.9%) were found to have clinical symptoms and ultimately underwent surgical excision with successful relief of symptoms. Peroneal tubercle hypertrophy appears to exist in the pediatric population; however, in contrast to adults with associated peroneal tendinopathy and tears, the children in our series had isolated painful tubercles without significant tendinopathy. The clinical examination is important in the diagnosis, and treatment by excision appears to be successful. Although a relatively rare etiology of pain, it is important that treating physicians keep this pathologic process in the differential diagnosis, because conservative management might not reduce the pain in these children.     

Differentiation between bone infarction and acute osteomyelitis in children with sickle-cell disease with use of sequential radionuclide bone-marrow and bone scans.

BACKGROUND: The differentiation of bone infarction from acute osteomyelitis in patients with sickle-cell disease is challenging, as the clinical presentations of the two conditions are similar and imaging and laboratory studies are of limited value. METHODS: A combination of radionuclide bone-marrow and bone scans was performed sequentially within a twenty-four-hour period (with one exception) to aid in the differentiation between bone infarction and osteomyelitis in seventy-nine consecutive episodes of acute bone pain in children with sickle-cell disease. RESULTS: Seventy cases of bone infarction were diagnosed on the basis of decreased uptake on the bone-marrow scan and abnormal uptake on the bone scan at the site of pain. Antibiotic administration was discontinued in sixty-six of the seventy cases after the imaging results were obtained, and the bone pain resolved. In four of the seventy-nine cases, there was normal uptake on the bone-marrow scan and abnormal uptake on the bone scan at the site of pain, findings that were suggestive of acute osteomyelitis. In three of these cases, osteomyelitis was proven by culture, and the symptoms in all four resolved with antibiotic treatment. In five of the seventy-nine cases, the bone-marrow and bone scans were normal and thought to indicate neither osteomyelitis nor bone infarction; in all of these cases, the symptoms resolved without the use of antibiotics. CONCLUSIONS: These findings suggest that osteomyelitis can be differentiated from bone infarction in children with sickle-cell anemia and acute bone pain by a combination of sequential bone-marrow and bone scintigraphy.     

Pediatric complex regional pain syndrome

Complex regional pain syndrome (CRPS) is a relatively new diagnostic entity in pediatrics. There is debate as to what constitutes the most effective treatment for pediatric CRPS. This study presents the patient characteristics, clinical course, and treatment outcome of 20 children diagnosed with CRPS at a major children's hospital during a 4-year period. The results showed that pediatric CRPS occurs predominantly in girls (90%) in later childhood and adolescence (mean age, 11.8 [range, 8-16 years]). It affects mainly the lower limbs (85%), with a predilection for the foot (75% of all cases), and was frequently initiated by minor trauma (80%). In many cases, there was a lengthy time to diagnosis (mean, 13.6 weeks) that delayed the institution of treatment, which consisted of intensive physiotherapy and psychological therapy. Most children (70%) required adjuvant medications (amitriptyline and/or gabapentin) for analgesia and to enable them to participate in physiotherapy. A high percentage of children had complete resolution of symptoms using this treatment regime (mean, 15.4 weeks [range, 3 days to 64 weeks]), but 40% required treatment as a hospital inpatient and 20% had a relapse episode. In conclusion, pediatric CRPS is under-recognized by clinicians, resulting in diagnostic delays, but has a favorable outcome to noninvasive treatment in that complete resolution of symptoms and signs occur in most patients. However, the lengthy period to achieve symptom resolution in some children and a high relapse rate support the need for further research into other treatment modalities.     

Bone scan: indium-WBC correlation in the diagnosis of osteomyelitis of the foot

A retrospective study was performed of 20 podiatric cases using technetium-99m methylene diphosphonate three-phase bone scans along with indium-111 oxine leukocyte scans, as needed, to determine the presence and extent of osteomyelitis of the foot. Using criteria developed at our institution, the authors attempt to provide a mechanism to make a reliable diagnosis for osteomyelitis that has been supported by surgical/pathologic confirmation of long-term clinical follow-up. The sensitivity, using bone scans alone, was 100%, and specificity was 47%. Correlating bone and indium-111 leukocyte scans yielded a sensitivity of 100% with a specificity raised to 81%. Indium-111 leukocyte scans were used in 40% of cases when a definitive diagnosis for osteomyelitis could not be made on the basis of the three-phase bone scan or clinical presentation alone. Indium-111 leukocyte scans were also helpful in delineating the extent of the disease process. The authors present a standard technique for a 5-hour delayed imaging in the three-phase bone scan, as well as marking the foot in the indium-111 leukocyte scan with three routine views obtained for each imaging procedure, to ensure clinical accuracy.     

Osteochondrosen des kindlichen Fußes

Osteochondrosis is a heterogeneous group of self-limiting conditions characterized by disturbance of enchondral ossification caused by a lack of circulation. Foot pain is a relatively common problem in children and adolescents and may be due to osteochondrosis. Osteochondrosis of the growing foot shows painful radiological alterations including increased density, fragmentation and irregularity of the epiphyses, physes and apophyses. Lacking etiologic and pathophysiologic information, ostoechondroses have been documented in almost every bone of the foot and therefore should be considered in the differential diagnosis when evaluating pediatric foot pain. The most common localizations of osteochondroses of the growing foot include the navicular as Kohler’s syndrome, the metatarsal as Freiberg’s infraction and calcaneal apophysitis as Sever’s disease. Prognosis and final outcome vary considerably between the different localizations. Physicians should therefore be informed about the etiology, clinical presentation and treatment options for osteochondroses of the growing foot.     

Evaluation of imaging in loosening of hip arthroplasty in 326 consecutive cases

Between 1989 and 1995, 326 hip arthroplasties were surgically revised in our clinic because of loosening. For evaluation of loosening, we used history, clinical examination, radiographs, bone scans and arthrography with digital subtraction technique. In 130 cases (40%), surgery was planned by plain radiographs. In 116 cases (89%) a correct diagnosis of loosened components was made. Of the 72 patients (22%) with an additional bone scan, 87% (63 patients) had a correct diagnosis. Fifty-four patients (17%) with different findings were examined by hip arthrography; in 83% (45 patients) the diagnosis was confirmed intraoperatively. In 93% (65 patients) of 70 patients (21%) with bone scans and arthrography, surgery confirmed the diagnosis. Sensitivity for loosening of the socket was 61% by bone scan and 85% by digital subtraction arthrography; specificity was 75% in each case. Sensitivity for loosening of the stem was 71% by bone scan and 65% by digital subtraction arthrography; specificity was 80% and 88%, respectively. Our results showed that in most cases of suspected loosening of total hip arthroplasties, analysis of plain radiograph series can lead to an accurate diagnosis in 85%–90%. In cases of uncertainty, we suggest the additional use of digital subtraction arthrography, which has a similarly high diagnostic quality. Because of the low sensitivity of nuclide bone scanning (about 60%) and its dependence on prosthetic material and fixation, we do not recommend primary scintigraphy. It can be helpful in problematic cases with additional questions like activity of ectopic bone formation. Received: 21 May 1997     

微型跟骨钢板应用于儿童跟骨骨折临床分析

目的探讨微型钛质跟骨钢板内固定治疗儿童跟骨骨折的临床疗效。方法我院诊治的40例跟骨骨折儿童患者,给予50例患足进行切开复位,微型钛质跟骨钢板内固定治疗,对其病例进行回顾性分析。结果 40例跟骨骨折儿童患者,50例患足,其中49例患足治愈出院,平均愈合时间为2个月,其中1例患儿出现切口愈合延迟的术后并发症,经过相应治疗也治愈出院。根据Margland足部评分标准,疗效优20例,良25例,可4例,差1例,优良率90.0%。结论对于跟骨骨折患者,微型钛质跟骨钢板内固定治疗,明显提高其临床疗效,而且减少术后并发症。     

Adapting pediatric DXA scanning to clinical orthopaedics

Osteoporosis and low bone density for age is increasingly recognized in children yet poorly understood and often overlooked. DXA scanning in children is problematic due to lack of guidelines and inexperience of most DXA practitioners. The International Society for Clinical Densitometry recommends spine or total body scans as the preferred skeletal sites for study in children, yet we find multiple regional scans to be far more useful in the clinical practice of pediatric DXA scanning, especially in a pediatric orthopaedic setting. DXA scans of 119 children are reviewed: 20% of the children had orthopaedic hardware or other artifact that would have rendered the whole body scan unusable. In 20 of 119 patients, the only scan that could be obtained, either due to contracture or patient cooperation, was the distal lateral femoral scan. Scanning multiple regions of interest including spine, hip, and/or distal lateral femora as indicated is the recommended protocol for assessment of BMD in the pediatric orthopaedic setting.     

Diagnostic Utility of Erythrocyte Sedimentation Rate and C-Reactive Protein in Osteomyelitis of the Foot in Persons Without Diabetes

The aim of the study was to assess the diagnostic value of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels in differentiating foot osteomyelitis (OM) from soft tissue infection (STI) in persons without diabetes. We evaluated 102 patients in a retrospective cohort study of nondiabetic patients admitted to our institution with OM (n = 51) and with STI (n = 51). Patient diagnosis was determined through bone culture and/or histopathology for OM and magnetic resonance scan and/or single-photon emission computed tomography for STI. Cutoffs for ESR and CRP to predict OM as identified by receiver operating characteristic were 45.5 mm/h and 3.45 mg/dL, respectively. The ESR cutoff demonstrated a sensitivity and specificity of 49% and 79%, while the values for CRP were 45% and 71%, respectively. The combined sensitivity and specificity for ESR and CRP were 33% and 84%. The positive and negative predictive values were 68% and 60% for ESR and 61% and 56% for CRP, respectively. In conclusion, ESR and CRP demonstrate poor sensitivity and specificity for detecting OM in the nondiabetic foot. These markers have little diagnostic utility in the nondiabetic foot.     

Foot-pain

Foot pain is a relatively common problem in children and adolescents. Most frequently the pain is localized at the heel, the mid- and forefoot are less common sites of discomfort. In this article we discuss the etiology of pain in those cases, where the foot has a normal clinical aspect. Sever's disease is most common in adolescents with strenuous athletic activity or with obesity. The calcaneal apophysis is overloaded. Usually the radiologic aspect of the calcis is normal. Treatment consists in reduction of the athletic activity, soft bedding of the heel in the shoes and reduction of weight. Avascular necrosis of the metatarsal head II or III (Freiberg's disease) is also relatively common, while necrosis of the navicular bone (K?hler's disease) is very rare. Treatment in these cases is always conservative. Pain can also originate from tarsal coalition. While in the beginning the foot has a normal aspect, lateron a rigid flatfoot can develop. In unclear cases stress fractures of the metatarsal bones, infections and tumors also have to be considered.     

Prevalence and importance of pneumothoraces visualized on abdominal computed tomographic scan in children with blunt trauma

BACKGROUND: Chest radiographs are routinely obtained for the identification of pneumothoraces in trauma patients. Computed tomographic (CT) scanning has a higher sensitivity for the detection of pneumothoraces, but the prevalence and importance of pneumothoraces detectable by CT scan but not by chest radiography in children sustaining blunt trauma is unclear. METHODS: We conducted a prospective observational cohort study of children less than 16 years old with blunt trauma undergoing both abdominal CT scan and chest radiography in the emergency department of a Level I trauma center over a 28-month period. All abdominal CT scans were interpreted by a single faculty radiologist. The chest radiographs of all patients with pneumothoraces detected on CT scan as well as a random sample of chest radiographs from pediatric blunt trauma patients without pneumothoraces on abdominal CT scan (in a ratio of four normals per pneumothorax) were reviewed by a second faculty radiologist. Both radiologists were masked to all clinical data as well as to the objective of the study. RESULTS: Five hundred thirty-eight children underwent both abdominal CT scan and chest radiography in the emergency department. Twenty patients (3.7%; 95% confidence interval [CI], 2.3-5.7%) were found to have pneumothoraces on CT scan. Of these 20 patients, 9 (45%; 95% CI, 23-68%) had pneumothoraces identified on initial chest radiography and 11 patients did not ("unsuspected pneumothoraces"). Twelve pneumothoraces were identified in these 11 patients; 6 were graded as minuscule and 6 as anterior according to a previously established scale. One patient with an unsuspected pneumothorax underwent tube thoracostomy. None of the 10 patients (0%; 95% CI, 0-26%) with unsuspected pneumothoraces who were managed without thoracostomy (including two patients who underwent positive pressure ventilation) had complications from their pneumothoraces. CONCLUSION: Less than half of pediatric blunt trauma patients with pneumothoraces visualized on abdominal CT scan had these pneumothoraces identified on initial chest radiograph. Patients with pneumothoraces identified solely on abdominal CT scan, however, uncommonly require tube thoracostomy.     

Retrospective review of osteoarticular infections in a pediatric sickle cell age group

Patients with sickle cell disease have been documented to be particularly susceptible to osteoarticular infections. Controversy exists concerning the bacteriology, etiology, and clinical presentation in differentiating osteoarticular infections from bone infarct. We retrospectively reviewed all cases from our institution over the past 22 years of osteoarticular infections in children who carry the diagnosis of sickle cell disease. Two thousand consecutive patient charts of children enrolled in the Pediatric Sickle Cell Clinic of our institution between 1973 and 1995 were evaluated. There were 14 cases of bone or joint infections (10 osteomyelitis, four septic arthritis). There was one case of multicentric osteomyelitis and one case of meningitis complicating the septic arthritis. There were nine male and five female patients with ages ranging from 6 months to 17 years (mean, 8.0). All patients were noted to have hemoglobin SS. The predominant presenting symptoms were pain (79% of cases) and swelling (71% of cases). The most frequent physical findings were fever >38.2 degrees C (71% of cases) and tenderness (86% of cases). Ninety-three percent of the children had a white blood count exceeding 15,000/mm3 (range, 7,900-32,300). Westergren sedimentation rates ranged from 14 to 89 mm/h with 93% of the children exceeding the normal value in our hospital. Cultures were positive in 75% of tissue biopsies, 58% of the blood cultures, and 70% of the bone or joint aspirates. The most common offending organism found in osteomyelitis was Salmonella (eight of 10 cases); however, no predominant organism found was identified in cases of septic arthritis. Radiographs and bone scans were of limited value in the differential diagnosis between osteoarticular infections and bone infarction. Early diagnosis and treatment of osteoarticular infections is key to satisfactory outcome. This study suggests that an ill-appearing patient with a fever >38.2 degrees C, pain, and swelling should prompt the physician to aspirate or biopsy the area and not rely on diagnostic studies that we found to be unreliable.     

Routine bone scans in patients with prostate cancer related to serum prostate-specific antigen and alkaline phosphatase

OBJECTIVE: To evaluate the need for a bone scan as a routine staging procedure in patients with newly diagnosed prostate cancer in relation to serum prostate-specific antigen (PSA) and alkaline phosphatase (ALP) levels, and thus determine whether a reduction of the use of this staging method is possible in patients with a low probability of osseous metastasis. PATIENTS AND METHODS: The results of bone scans were related retrospectively to levels of serum PSA and ALP in 363 patients with prostate cancer newly diagnosed between 1989 and 1997. RESULTS: Of 363 consecutive patients, 111 had a positive bone scan. In 19 of 144 (13%, "missed diagnosis") patients with a PSA level of < 20 ng/mL the bone scan was positive. In 125 patients (49%, "false-positives") with a PSA level of > 20 ng/mL the bone scan was negative. A threshold level of 100 U/L for ALP gave a better balance for the number of "false-positives" and "missed diagnosis". ALP values correlated better with an abnormal bone scan than did PSA levels; ALP levels of > 90 U/L indicated a 60% chance for the presence of bone metastases. CONCLUSION: Patients with newly diagnosed and untreated prostate cancer should undergo bone scintigraphy if there is bone pain or if ALP levels are > 90 U/L. Recent reports discourage the routine use of a bone scan when the serum PSA level is <20 ng/mL. However, the present series suggests there is a greater chance of a positive bone scan in patients with low PSA levels; these findings need further confirmation.     

Management of vocal paralysis: a comparison of adult and pediatric practices.

OBJECTIVE: To compare practices of the American Broncho-Esophagological Association (ABEA) membership regarding the evaluation and management of unilateral vocal fold motion impairment (UVFMI) in adult versus pediatric populations. STUDY DESIGN AND SETTING: An 18-item adult survey and 16-item pediatric survey were administered to ABEA members. RESULTS: Seventy-six adult (31%) and 35 pediatric surveys (43%) were completed. Key differences are highlighted. With respect to etiology, the most common reported childhood cause is idiopathic; adults more often suffer iatrogenic paralysis. Children more commonly experience reflux disease, feeding difficulties, and choking. Preferred testing involves flexible laryngoscopy and chest x-ray; however, laboratory tests are carried out less often in children (51% vs 71%) and medical intervention is advocated by fewer pediatric practitioners (39% vs 57%). CONCLUSION: Significant disparities exist in the etiology, presenting symptoms, diagnostic testing, and medical treatment between children and adults with UVFMI. SIGNIFICANCE: Clinicians' perceptions regarding UVFMI may reflect the differing impact of vocal paralysis in the pediatric versus adult populations.     

The comparative values of bone marrow aspirate and trephine for obtaining bone scan-targeted metastases from hormone-refractory prostate cancer

Samples of metastatic prostate cancer to bone are difficult to obtain. The aim of this study was to compare the results of bone marrow aspirate and trephine biopsy for obtaining metastatic hormone-refractory prostate cancer (HRPC) samples using previous diagnostic planar 99(m)Tc-HDP bone scans to guide the procedure. All samples taken were for the purposes of research and molecular studies on HRPC. Twenty patients with HRPC had bone marrow aspirate and trephines taken from lesions in the posterior superior iliac spine or sacro-iliac region when shown on diagnostic 99(m)Tc-HDP bone scans. Three patients also underwent plain X-ray, 18F-positron emission tomography bone scan, pelvic MRI scan and 99(m)Tc nanocolloid bone marrow scans. These images were used to assess if the extra imaging information provided, such as three-dimensional localisation of the bone metastases, was of value for target bone metastases. Cancer cells were obtained in 15/20 (75%) cases in which a trephine biopsy was attempted and 0/20 of cases in which a bone marrow aspiration was attempted. The additional information provided by the range of other imaging investigations was of little benefit in obtaining tumour samples, but did suggest why negative biopsies were obtained in some cases after targeting with planar bone scans. We recommend the use of bone marrow trephine biopsy alone, guided by previous diagnostic 99(m)Tc planar bone scan as a practical method to obtain prostate cancer cells from bone metastases.     

18例儿童足部骨髓炎临床特征分析

目的 总结儿童足部骨髓炎临床特点及诊治体会。方法 收集2017年9月至2023年1月山东大学附属儿童医院诊治的18例儿童足部骨髓炎的病例资料进行回顾性分析，其中男孩13例，女孩5例，年龄为1个月14天~11岁，就诊时发病时长为3天~2个月。发病部位跟骨6例，趾骨4例，跖骨4例，距骨3例，足舟骨1例。18例患儿起病时均表现为患处肿胀压痛，16例伴有患处皮温高，7例起病时无明显诱因，9例发病过程中伴有发热。8例入院前于外院行抗生素治疗，4例入院前于外院行抗生素联合软组织清创引流。入院后2例患儿采用抗生素保守治疗，16例患儿采用抗生素联合骨质开窗引流。结果 入院24小时内实验室检查13例白细胞升高，8例中性粒细胞升高，11例C-反应蛋白升高，15例红细胞沉降率升高。所有患儿均行MRI检查提示骨质异常信号。血培养仅有1例患儿阳性，为耐甲氧西林金黄色葡萄球菌。行手术治疗的16例患儿中脓液培养6例为甲氧西林敏感性金黄色葡萄球菌，2例为耐甲氧西林金黄色葡萄球菌，1例为肺炎链球菌，1例同时有甲氧西林敏感性金黄色葡萄球菌和化脓性链球菌。住院总时间为11~49 d，所有患儿均治愈。其中1例发病过程中伴有大隐静脉血栓性静脉炎，1个月后复查血栓消失，血管完全再通；1例残留足部畸形；1例足趾短缩。结论 儿童足部骨髓炎比较少见，临床多表现为足部肿胀压痛，多数起病时有明显诱因，治疗上积极采用抗生素，保守治疗效果欠佳时需行清创引流。     

Osteonecrosis in the foot

Osteonecrosis, also referred to as avascular necrosis, refers to the death of cells within bone caused by a lack of circulation. It has been documented in bones throughout the body. In the foot, osteonecrosis is most commonly seen in the talus, the first and second metatarsals, and the navicular. Although uncommon, osteonecrosis has been documented in almost every bone of the foot and therefore should be considered in the differential diagnosis when evaluating both adult and pediatric foot pain. Osteonecrosis is associated with many foot problems, including fractures of the talar neck and navicular as well as Kohler's disease and Freiberg's disease. Orthopaedists who manage foot disorders will at some point likely be faced with the challenges associated with patients with osteonecrosis of the foot. Because this disease can masquerade as many other pathologies, physicians should be aware of the etiology, presentation, and treatment options for osteonecrosis in the foot.     

Bone mineral density deficiency in children.

With the development of improved diagnostic and treatment options, reduced bone mineral density in children is receiving increased attention. The etiology of osteopenia in healthy children is multifactorial and incompletely understood, but poor calcium intake during the adolescent growth spurt may be an important (and potentially reversible) factor. Other clinically relevant causes of reduced bone mineral density in children include osteogenesis imperfecta, rickets, juvenile rheumatoid and other chronic arthritides, osteopenia associated with neuromuscular disorders, and idiopathic osteoporosis. To provide effective treatment, it is important to understand the process of normal skeletal mineralization, the techniques of bone mineral density measurement, the pathophysiology of osteopenia, and the evaluation and treatment options for the general pediatric population as well as for patients with specific pediatric disorders.     

Imaging modalities of the diabetic foot

Charcot osteoarthropathy is a devastating process that occurs in the diabetic foot. It must be distinguished from other conditions, such as osteomyelitis, with efficiency and accuracy. The prognosis and treatment depends on it. Charcot progresses along four radiographically identifiable stages; therefore, plain films should be the first step in the evaluation. When osteomyelitis is suspected, a three-phase bone scan may allow clear enough anatomic detail to diagnosis bony involvement compared with soft tissue in the forefoot. In the midfoot, a three-phase bone scan alone is not specific enough to distinguish between Charcot and osteomyelitis. Enhancing the bone scans by adding an additional phase (four-phase) or tracer (gallium) does not appear to improve specificity significantly. Computerized bone flow studies may be more helpful in making the distinction, particularly in acute presentation. A CT scan is not indicated because the MR image will better define the anatomic extent of the process for preoperative planning. The combined WBC scans and sulfur colloid marrow scans show improved specificity and can distinguish between Charcot and osteomyelitis. Combined leukocyte scan with bone marrow imaging is superior to leukocyte and bone scan alone or in combination for detecting infection in the neuropathic foot. The combined leukocyte scan and bone marrow imaging is the current gold standard for evaluating the presence of diabetic foot infection versus osteoarthropathy, and MR imagine is the anatomic gold standard that may be used to define the extent of the process.