Basal cell carcinoma of skin of right lower limb, including hip. Methicillin-resistant Staphylococcus aureus infection. Shin ulcer, history of osteomyelitis, skin cancer, radiation therapy to legs, diabetes. Evaluate for osteomyelitis. Right tibia/fibula: Again seen is ulceration of the anterior soft tissues of the lower leg approximately 6 cm above the level of the tibiotalar joint. As seen on the previous study, the signal abnormality associated with the ulcer extends through the anterior tibial cortex into the medullary bone, compatible with chronic osteomyelitis. The region of affected bone appears larger on the current study than on the prior study, with an enhancing rim that nearly abuts the posterior endosteum of the tibia. Beyond this enhancing margin, there is little, if any, edema in the adjacent medullary bone, and the remainder of the tibia is unremarkable with the exception of chronic periosteal reaction distally. The signal intensity of the fibula is likewise normal; chronic periosteal reaction distally appears similar to that seen on the prior study. There is enhancement of the skin of the lower leg and ankle suggesting cellulitis, with signal abnormality in the underlying subcutaneous fat likely representing a combination of edema and scarring. There is replacement of the anterior subcutaneous fat of the shin above the aforementioned ulcer with intermediate signal intensity on T1-weighted images and heterogeneous increased signal intensity on T2-weighted images. This tissue enhances slightly following gadolinium administration. I suspect that this represents a surgically created flap, and although I cannot exclude the possibility of superimposed tumor or infection, overall this appears similar to the prior study. I see no rim-enhancing fluid collection to confirm a soft tissue abscess. Bandlike scarring traverses the subcutaneous fat medially, also appearing similar to that seen on the prior study. There is a small knee joint effusion with synovial enhancement indicating a mild synovitis.Right forefoot/midfoot: There is a hallux valgus deformity with mild osteoarthritis of the first metatarsophalangeal joint, but I see no findings to suggest osteomyelitis of the first ray. The second toe has been amputated through the base of the proximal phalanx. I see no findings to suggest osteomyelitis of the second ray. The distal phalanx as well as the majority of the middle phalanx of the third toe are absent, presumably due to surgical resection. There is normal fat signal intensity of the proximal phalanx and remaining base of the middle phalanx, arguing against osteomyelitis. There is mild edema and enhancement of the adjacent soft tissues, with small foci of low signal intensity distal to the head of the proximal phalanx that may reflect surgical suture or subcutaneous gas. There is mild edema and enhancement of the soft tissues of the remaining fourth toe. There is also mild edema on the fat-suppressed T2-weighted images within the distal half of the proximal phalanx with relative preservation of fat signal intensity on T1-weighted images suggesting reactive osteitis rather than osteomyelitis. The distal phalanx and middle phalanx of the fourth toe are not visible, probably due to surgical resection or sequela of long-standing infection. There is a biphalangeal fifth toe. There is mild edema-type signal within the distal phalanx on the fat-suppressed T2-weighted images, with relative preservation of normal fatty signal on the T1-weighted images suggesting reactive osteitis rather than osteomyelitis. The signal intensity of the proximal phalanx of the fifth toe appears normal. The signal intensity of the metatarsals and bones of the midfoot is normal. The skin of the along the dorsum of the foot appears thickened with mild enhancement and underlying subcutaneous edema suggesting cellulitis. There is atrophy of the plantar musculature of the foot.
1.Right lower leg ulcer with underlying chronic osteomyelitis of the tibia and other findings as above.2.Soft tissue inflammation of the right forefoot and midfoot with imaging features of reactive osteitis but no specific features of osteomyelitis.