Bony abnormalities of the hip joint: a new comprehensive, reliable and radiation-free measurement method using magnetic resonance imaging

The objective of this study was to develop comprehensive and reliable radiation-free methods to quantify femoral and acetabular morphology using magnetic resonance imaging (MRI). Thirty-two hips [16 subjects, 6 with intra-articular hip disorder (IAHD); 10 controls] were included. A 1.5-T magnetic resonance system was used to obtain three-dimensional fat-suppressed gradient-echo images at the pelvis and distal femora. After acquisition, pelvic images were post-processed to correct for coronal, axial and sagittal rotation. Measurements performed included acetabular version (AV), femoral version (FV), lateral center-edge angle (LCEA), femoral neck angle (FNA) and alpha angle (AA) at 3, 2, 1 and 12 a.m. Two experienced raters, a musculoskeletal radiologist and an orthopedic physical therapist, and a novice rater, a research assistant, completed reliability testing. Raters measured all hips twice with minimum 2 weeks between sessions. Intra-class Correlation Coefficients (ICCs) were used to determine rater reliability; standard error of measurements was reported to estimate the reasonable limits of the expected error in the different raters’ scores. Inter-rater reliability was good to excellent for all raters for AV, FV, FNA and LCEA (ICCs: 0.82–0.98); good to excellent between experienced raters (ICCs: 0.78–0.86) and poor to good between novice and experienced raters (ICCs: 0.23–0.78) for AA. Intra-rater reliability was good to excellent for all raters for AV, FV and FNA (ICCs: 0.93–0.99); for one experienced and novice rater for LCEA (ICCs: 0.84–0.89); moderate to excellent for the experienced raters for AA (ICCs: 0.72-0.89). Intra-rater reliability was poor for the second experienced rater for LCEA (ICC: 0.56), due to a single measurement error and for the novice rater for AA (ICCs: 0.17–0.38). We described MRI methods to comprehensively assess femoral and acetabular morphology. Measurements such as AV, FV and FNA and the LCEA can be made reliably by both experienced and novice raters; however, the AA measurement was reliable only among experienced raters

Soft-tissue abnormalities associated with treatment-resistant and treatment-responsive clubfoot: Findings of MRI analysis

BACKGROUND: Clubfoot treatment commonly fails and often results in impaired quality of life. An understanding of the soft-tissue abnormalities associated with both treatment-responsive and treatment-resistant clubfoot is important to improving the diagnosis of clubfoot, the prognosis for patients, and treatment. METHODS: Twenty patients with clubfoot treated with the Ponseti method were recruited for magnetic resonance imaging (MRI) of their lower extremities. Among these were seven patients (six unilateral cases) with treatment-responsive clubfoot and thirteen patients (five unilateral cases) with treatment-resistant clubfoot. Demographic information and physical examination findings were recorded. A descriptive analysis of the soft-tissue abnormalities was performed for both patient cohorts. For the patients with unilateral clubfoot, we calculated the percentage difference in cross-sectional area between the affected limb and the unaffected limb in terms of muscle, subcutaneous fat, intracompartment fat, and total area. With use of the Wilcoxon signed-rank test, we compared inter-leg differences in cross-sectional areas and the intracompartment adiposity index (IAI) between treatment-responsive and treatment-resistant groups. The IAI characterizes the cross-sectional area of fat within a muscle compartment. RESULTS: Extensive soft-tissue abnormalities were more present in patients with treatment-resistant clubfoot than in patients with treatment-responsive clubfoot. Treatment-resistant clubfoot abnormalities included excess epimysial fat and intramuscular fat replacement as well as unique patterns of hypoplasia in specific muscle groups that were present within a subset of patients. Among the unilateral cases, treatment-resistant clubfoot was associated with a significantly greater difference in muscle area between the affected and unaffected limb (−47.8%) compared with treatment-responsive clubfoot (−26.6%) (p = 0.02), a significantly greater difference in intracompartment fat area between the affected and unaffected limb (402.6%) compared with treatment-responsive clubfoot (9%) (p = 0.01), and a corresponding higher inter-leg IAI ratio (8.7) compared with treatment-responsive clubfoot (1.5) (p = 0.01). CONCLUSIONS: MRI demonstrated a range of soft-tissue abnormalities in patients, including unique patterns of specific muscle-compartment aplasia/hypoplasia that were present in patients with treatment-resistant clubfoot and not present in patients with treatment-responsive clubfoot. Correlations between MRI, physical examination, and treatment responsiveness may aid in the development of a prognostic classification system for clubfoot. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence

Multi-system factors associated with metatarsophalangeal joint deformity in individuals with type 2 diabetes

The underlying factors contributing to metatarsophalangeal joint deformity, a known precursor to skin breakdown in individuals with diabetes mellitus (DM), is likely to involve multiple body systems. The purpose of this cross-sectional study was to identify multi-system factors associated with metatarsophalangeal joint deformity in individuals with type 2 DM and peripheral neuropathy

Rate of tarsal and metatarsal bone mineral density change in adults with diabetes mellitus and peripheral neuropathy: A longitudinal study

BACKGROUND: In people with diabetes (DM) and peripheral neuropathy (PN), loss of bone mineral density (BMD) in the tarsals and metatarsals contribute to foot complications; however, changes in BMD of the calcaneal bone is most commonly reported. This study reports rate of change in BMD of all the individual bones in the foot, in participants with DM and PN. Our aim was to investigate whether the rate of BMD change is similar across all the bones of the foot. METHODS: Participants with DM and PN (n = 60) were included in this longitudinal cohort study. Rate of BMD change of individual bones was monitored using computed tomography at baseline and 6 months, 18 months, and 3-4 years from baseline. Personal factors (age, sex, medication use, step count, sedentary time, and PN severity) were assessed. A random coefficient model estimated rate of change of BMD in all bones and Pearson correlation tested relationships between personal factor variables and rate of BMD change. RESULTS: Mean and calcaneal BMD decreased over the study period (p \u3c 0.05). Individual tarsal and metatarsal bones present a range of rate of BMD change (-0.3 to -0.9%/year) but were not significantly different than calcaneal BMD change. Only age showed significant correlation with BMD and rate of BMD change. CONCLUSION: The rate of BMD change did not significantly differ across different foot bones at the group level in people with DM and PN without foot deformity. Asymmetric BMD loss between individual bones of the foot and aging may be indicators of pathologic changes and require further investigation. TRIAL REGISTRATION: Metatarsal Phalangeal Joint Deformity Progression-R01. Registered 25 November 2015, https://clinicaltrials.gov/ct2/show/NCT02616263

Muscle and Joint Factors Associated With Forefoot Deformity in the Diabetic Neuropathic Foot

BackgroundDiabetic forefoot joint deformities are a known risk factor for skin breakdown and amputation, but the causes of deformity are not well understood. The purposes of this study were to determine the effects of intrinsic foot muscle deterioration and limited ankle joint mobility on the severity of metatarsophalangeal joint (MTPJ) deformity, and determine the relationships between these potential contributing factors and indicators of diabetic complications (peripheral neuropathy and advanced glycation end products).MethodsA total of 34 participants with diabetic neuropathy (average age, 59 years; range 41-73) were studied. MTPJ angle and intrinsic foot muscle deterioration were measured with computed tomography and magnetic resonance imaging, respectively. Maximum ankle dorsiflexion was measured using kinematics. Skin intrinsic fluorescence served as a proxy measure for advanced glycation end product accumulation.ResultsTotal forefoot lean muscle volume (r = -0.52, P < .01) and maximum ankle dorsiflexion (r = -0.42, P < .05) were correlated with severity of MTPJ deformity. Together they explained 35% of the variance of MTPJ angle. Neuropathy was correlated with forefoot muscle deterioration (ρ = 0.53, P < .01). Skin intrinsic fluorescence was correlated to severity of neuropathy (r = 0.50, P < .01) but not maximum ankle dorsiflexion, or forefoot deterioration when controlling for neuropathy.ConclusionThese results suggest that the interplay of intrinsic foot muscle deterioration and limited ankle mobility may be the primary contributor to the development of MTPJ deformity. Identifying these muscle and ankle motion impairments as risk factors for MTPJ deformity supports the need for targeted interventions early in the disease process to slow, or possibly stop the progression of deformity over time and reduce the risk of amputation.Level of evidenceLevel IV, case series

Reliability and validity of a MR‐based volumetric analysis of the intrinsic foot muscles

PurposeTo describe a semi-automated program that will segment subcutaneous fat, muscle, and adipose tissue in the foot using MR imaging, determine the reliability of the program between and within raters, and determine the validity of the program using MR phantoms.Materials and methodsMR images were acquired from 19 subjects with and without diabetes and peripheral neuropathy. Two raters segmented and measured volumes from single MR slices at the forefoot, midfoot, and hindfoot at two different times. Intra- and inter-rater correlation coefficients were determined. Muscle and fat MR phantoms of known volumes were measured by the program.ResultsMost ICC reliability values were over 0.950. Validity estimates comparing MR estimates and known volumes resulted in r(2) values above 0.970 for all phantoms. The root mean square error was less than 5% for all phantoms.ConclusionSubcutaneous fat, lean muscle, and adipose tissue volumes in the foot can be quantified in a reliable and valid way. This program can be applied in future studies investigating the relationship of these foot structures to functions in important pathologies, including the neuropathic foot or other musculoskeletal problems

Muscle and Joint Factors Associated With Forefoot Deformity in the Diabetic Neuropathic Foot

BACKGROUND: Diabetic forefoot joint deformities are a known risk factor for skin breakdown and amputation, but the causes of deformity are not well understood. The purposes of this study were to determine the effects of intrinsic foot muscle deterioration and limited ankle joint mobility on the severity of metatarsophalangeal joint (MTPJ) deformity, and determine the relationships between these potential contributing factors and indicators of diabetic complications (peripheral neuropathy and advanced glycation end products). METHODS: A total of 34 participants with diabetic neuropathy (average age, 59 years; range 41-73) were studied. MTPJ angle and intrinsic foot muscle deterioration were measured with computed tomography and magnetic resonance imaging, respectively. Maximum ankle dorsiflexion was measured using kinematics. Skin intrinsic fluorescence served as a proxy measure for advanced glycation end product accumulation. RESULTS: Total forefoot lean muscle volume (r = −0.52, P < .01) and maximum ankle dorsiflexion (r = −0.42, P < .05) were correlated with severity of MTPJ deformity. Together they explained 35% of the variance of MTPJ angle. Neuropathy was correlated with forefoot muscle deterioration (ρ = 0.53, P < .01). Skin intrinsic fluorescence was correlated to severity of neuropathy (r = 0.50, P < .01) but not maximum ankle dorsiflexion, or forefoot deterioration when controlling for neuropathy. CONCLUSION: These results suggest that the interplay of intrinsic foot muscle deterioration and limited ankle mobility may be the primary contributor to the development of MTPJ deformity. Identifying these muscle and ankle motion impairments as risk factors for MTPJ deformity supports the need for targeted interventions early in the disease process to slow, or possibly stop the progression of deformity over time and reduce the risk of amputation. LEVEL OF EVIDENCE: Level IV, case series

Intrinsic foot muscle deterioration is associated with metatarsophalangeal joint angle in people with diabetes and neuropathy

BackgroundMetatarsophalangeal joint deformity is associated with skin breakdown and amputation. The aims of this study were to compare intrinsic foot muscle deterioration ratios (ratio of adipose to muscle volume), and physical performance in subjects with diabetic neuropathy to controls, and determine their associations with 1) metatarsophalangeal joint angle and 2) history of foot ulcer.Methods23 diabetic, neuropathic subjects [59 (SD 10) years] and 12 age-matched controls [57 (SD 14) years] were studied. Radiographs and MRI were used to measure metatarsophalangeal joint angle and intrinsic foot muscle deterioration through tissue segmentation by image signal intensity. The Foot and Ankle Ability Measure evaluated physical performance.FindingsThe diabetic, neuropathic group had a higher muscle deterioration ratio [1.6 (SD 1.2) vs. 0.3 (SD 0.2), P&lt;0.001], and lower Foot and Ankle Ability Measure scores [65.1 (SD 24.4) vs. 98.3 (SD 3.3) %, P&lt;0.01]. The correlation between muscle deterioration ratio and metatarsophalangeal joint angle was r=-0.51 (P=0.01) for all diabetic, neuropathic subjects, but increased to r=-0.81 (P&lt;0.01) when only subjects with muscle deterioration ratios &gt;1.0 were included. Muscle deterioration ratios in individuals with diabetic neuropathy were higher for those with a history of ulcers.InterpretationIndividuals with diabetic neuropathy had increased intrinsic foot muscle deterioration, which was associated with second metatarsophalangeal joint angle and history of ulceration. Additional research is required to understand how foot muscle deterioration interacts with other impairments leading to forefoot deformity and skin breakdown