Postoperative Foot and Ankle MR Imaging

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Key points

  • MR imaging of postoperative tendon repair, reconstruction, and augmentation are potentially challenging examinations to interpret. Clinical history is important when interpreting these cases.

  • Postoperative tendon appearance varies by time from surgery.

  • There are a variety of operative approaches for lateral collateral ligament reconstruction.

  • Abnormal findings on postoperative imaging may not correlate with symptoms.

  • A variety of MR imaging sequences is used to differentiate osteomyelitis from

MR imaging

MR imaging is the favored imaging modality for evaluating the ankle and foot following surgery because of the excellent contrast resolution. In particular, MR imaging is sensitive in evaluating postoperative bone marrow response and in evaluating surrounding soft tissues, including the tendons and ligaments.

MR imaging artifacts generated from implanted metallic objects in the magnetic field are a significant obstacle to obtaining clinically relevant postsurgical MR imaging. Magnetic field

Tendon repair and reconstruction

There are many tendon procedures involving the foot and ankle, many of which are named. MR imaging findings may be confusing, particularly if the surgical history is limited. A few principles help guide MR imaging interpretation. Tendons may be repaired directly, reconstructed with tendon graft, and/or augmented by nearby tendons. Augmentations may be the most difficult to evaluate on imaging because tendons may be rerouted, divided, and/or anchored at new locations to support the failed tendon.

Ankle lateral collateral ligaments

Ankle inversion injuries may result in damage to the lateral collateral ligaments, most commonly the anterior talofibular ligament, followed by the calcaneofibular ligament. The posterior talofibular ligament is nearly always spared. Treatment of a single event is nonoperative, involving rest, rehabilitation, and bracing. With repeated injuries, ligamentous laxity and instability may develop, necessitating operative intervention.35

Many procedures and modifications for lateral collateral

Ankle medial collateral ligaments

The deltoid ligament complex stabilizes the medial ankle. The deltoid is less frequently injured compared with the lateral collateral complex. Physical examination and radiographs are limited for detecting deltoid ligament injuries, whereas MR imaging can be quite helpful.38 Although individual ligaments may be delineated on anatomic studies, for practical surgical (and imaging) purposes, the deltoid ligament complex is divided into superficial and deep components. The superficial deltoid is

Morton neuroma-interdigital perineural fibrosis

Morton neuroma reflects interdigital perineural fibrosis in the plantar aspect of the intermetatarsal space, deep to the transverse metatarsal ligament, and near the common plantar digital nerve, perhaps due to entrapment and repetitive irritation. Interdigital fibrosis occurs most of the time at the third interspace with perhaps one-third of cases located at the second interspace.42 Occurrence in either the first or fourth interspace is rare, likely due to the larger size of these spaces

Coalition

Almost all tarsal bone coalitions are either calcaneonavicular or talocalcaneal coalitions. Although most calcaneonavicular coalitions present in children (8–12 year olds), talocalcaneal coalitions are commonly identified in young adults (teens to early 20s).54 In the authors’ experience, many coalitions are detected incidentally in adults even at middle-age or older during MR imaging and computed tomography (CT) evaluation, often for unrelated problems. For imaging purposes, coalitions are

Stress Injury or Fracture

Altered biomechanics following ankle and foot surgery result in new weightbearing stresses on adjacent bones, particularly in the forefoot. This may result in a stress injury or fracture near operative sites.61 MR imaging is helpful for delineating stress reactions and early fractures that may remain occult on radiographs.62 Intramedullary and periosteal edema, either alone or in combination, indicate a stress injury (Fig. 7). Hyperintense intracortical signal on fluid-sensitive sequences most

Summary

MR imaging is a useful problem-solving tool for the postoperative foot and ankle. MR imaging readily depicts operative sequela across a range of surgical procedures and related pathologic conditions, including tendon and ligament reconstruction, tarsal coalition, and interdigital perineural fibrosis. Surgical complications may be identified as well. MR imaging provides valuable information for guiding the care of postoperative foot and ankle patients.

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