Supplemental Figure 1 Correlation analysis of tracer between and subsequent as assessed by SUV max in focal lesions (A). x-axis displays quantitative values as obtained by, and y-axis displays corresponding values by. High correlations as expressed by the Spearman correlation coefficient (R) are found for SUV max (R = 0.96) between findings from both modalities. The difference between the two SUV measurements is shown by the Bland Altman plot (B), on which the difference between 2 SUV measurements is plotted against their average: For SUV max the mean difference is +0.6 SUV; the 95% CI is +11.4 and 10.2 SUV.
Supplemental Figure 2 Consecutively performed 18 F-fluoride and images using a single-injection dual-imaging protocol in a 22-y-old man with pain in the upper ankle joint without trauma (patient 21). Sagittal CT scan demonstrates a central osteolysis of the talar bone with slightly sclerotic margins (arrow, A). An intense 18 F-fluoride in (D), PET of (E), and (F) was found in the adjacent bone. However, the diagnosis remained unclear after CT and PET imaging. MR images show a multicystic lesion with fluid fluid levels and a low-signal rim on fluid-sensitive sequences (arrow, B and C) surrounded by BME, which was regarded as highly suggestive of an aneurysmatic bone cyst with secondary/reactive bone remodeling in the adjacent talus.
Supplemental Figure 3 18 F-fluoride and images of a 60-y-old woman (patient 9) with pain in the right upper ankle joint without trauma. Sagittal MR images show low signal intensity on the T1-weighted image (arrow, A) with corresponding ill-defined hyperintense signal intensity on proton density weighted sequence with fat suppression (arrow, B) representing bone marrow edema in the talar head. Both fused and (C and D) show intense 18 F-fluoride representing a stress reaction. Follow-up 18 F- fluoride and were performed 12 mo later because of persistent pain in the right foot. Formerly observed BME-like signal alterations on MR imaging fully disappeared (E and F) and there was no pathologic 18 F-fluoride anymore (G and H).
Supplemental Table 1. Summary of Patient Characteristics, Including Symptoms, Findings, and Diagnoses in and No. Sex Age (y) 1 f 20 2 f 58 3 f 45 4 f 78 5 m 25 6 m 29 7 f 49 Symptoms Pain OMT III-V 10 days after a long hike Several months of pain in calcaneocuboidal joint without trauma Progressive pain of OMT III/IV after Weber B fracture Diffuse metatarsal pain, no weight bearing Pain OMT V after a sudden snap without a trauma Chronic pain over dorsal foot Pain for several months without trauma 8 m 28 Pain over OMT V 9 f 60 Pain in ankle joint 10 f 64 11 f 67 Metatarsalgia for 6 mo without trauma Pain in both feet for 3 y without trauma Findings by (a PET, b MR) Diagnosis by (1= diagnostic, 2=suspicious) Findings by (a PET, b CT) Diagnosis by (1= diagnostic, 2=suspicious) a) Little to moderate in midfoot and hindfoot Soft-tissue edema (1) Secondary/reactive changes due to immobilization (2) b) Little fluid in soft tissue of dorsal foot b) Unremarkable a) Cuboid bone: intense ; anterior calcaneal process: moderate ; calcaneus: low b) Cuboid bone: T1 hypointense line, BME; anterior calcaneal process: little BME; calcaneus: T1 hypointense line, absence of BME Cuboid: acute stress fracture (1); anterior calcaneal process: stress reaction (1); calcaneus: old stress fracture (1) a) Caput OMT III/IV: intense Caput OMT III/ IV: stress b) Caput OMT III/IV: BME, no reaction(1) hypointense line on T1 a) Several foot joints: intense b) Several foot joints: signs of degeneration a) Base OMT V: intense Stress fracture base OMT V b) Base OMT V: T1 hypointense line, (1) hyperintense BME on PD fs b) Hyperintense signal alterations and Tenosynovitis of extensor fluid along extensor tendon sheath on compartment (1) PD fs b) Cuboid: unremarkable ; anterior calcaneal process: unremarkable; calcaneus: sclerotic fracture line Cuboid bone: stress reaction (2); anterior calcaneal process: stress reaction (2); calcaneus: old stress fracture (1) Caput OMT III/IV: stress reaction (2) b) Unremarkable ; b) Typical findings of OA, inferior inferior calcaneal spur (1) calcaneal spur only seen on CT Stress fracture base OMT V b) Sclerotic fracture line base OMT (1) V b) Unremarkable a) Base OMT I: intense ; caput Base OMT I: stress fracture OMT IV: intense ; (1); caput OMT IV: stress b) Base OMT I: T1 hypointense line, b) Base OMT I: sclerotic fracture reaction (1) BME on PD fs; caput OMT IV: BME line Unremarkable b) Unremarkable b) Unremarkable a) Caput tali: intense Stress reaction caput tali (1) b) Caput tali: BME b) Unremarkable a) Medial malleolus: intense ; 1st TM: moderate ; anterior calcaneus: moderate b) Medial malleolus: osteophyte probable; 1st TM: osteophyte probable; inferior calcaneal spur a) Several joints of foot: intense ; 2nd phalanx: intense b) Several joints of foot: signs of degeneration; 2nd phalanx: BME OA of several joints (2); Achilles tendon enthesopathy with inferior calcaneal spur (1) ; stress reaction second phalanx (1) b) Medial malleolus: osteophyte; first tarsometatarsal joint: osteophyte; inferior calcaneal spur b) Typical findings of OA; unremarkable second phalanx Stress fracture base OMT I (1); stress reaction caput OMT IV (2) Unremarkable Stress reaction caput tali (2) ; enthesopathy inferior calcaneal spur (1), stress reaction second phalanx (2) Modality of choice for final diagnosis (visualization of soft-tissue pathologies) reaction/stress fracture) (additional calcaneal spur) and equal (more specific for soft-tissue pathologies) reaction/stress fracture) (better visualization of osteophytes and degenerative changes, additional calcaneal spur)
12 f 62 Instability of foot 13 m 61 14 m 43 15* f 54 16 f 60 17 m 27 18 m 55 19 f 57 Metatarsalgia without trauma Surgery of lateral collateral ligament 3 y ago Trimalleolar fracture 5 y ago Metatarsalgia without trauma Chronic instability of ankle joint after surgical reconstruction Persistent pain and swelling of foot for several years Pain over medial back of foot without trauma a) Anterior calcaneal process: intense ; several joints of foot: intense b) Anterior calcaneal process: BME; several joints of foot: signs of degeneration a) Os cuneiforme mediale: intense ; malleolus medialis: moderate b) Os cuneiforme mediale: BME, subchondral cysts; malleolus medialis: BME, subchondral cysts a) Ankle/subtalar joint: intense ; caput OMT I: intense ; caput OMT II/base proximal phalanx: intense b) In several joints signs of degeneration; BME caput OMT II/base Anterior calcaneal process: stress reaction (1); OA of several joints (1), stress reaction caput OMT II (1) proximal phalanx a) Fibular insertion of lateral collateral ligament: intense ; os trigonum: intense Postoperative changes (2), b) Fibular insertion of lateral collateral ligament: BME fibula, peroneal tenosynovitis; os trigonum: BME a) Ankle joint: intense b) Ankle joint: signs of degeneration and posttraumatic osseus defects with contrast enhancement a) Tarsometatarsal joints: intense ; ankle joint: intense ; calcaneus: low b) Signs of degeneration in joints mentioned above; calcaneus: intraosseous cyst on PD fs a) Medial talar dome: intense b) Osteochondral lesion of talus without dislocation at medial talar dome a) Subtalar joint: intense ; tarsometatarsal joint: intense ; os tibiale externum: low b) Signs of degeneration in abovementioned regions; os tibiale externum; PD fs ganglion cyst originating from subtalar joint os trigonum syndrome (1) OA secondary to trimalleolar fracture ; intraosseous ganglion cyst in calcaneus originating from tarsal sinus (1) Osteochondral lesion of talus (1), large ganglion cyst (1) b) Typical findings of OA; unremarkable anterior calcaneal process b) Typical findings of OA b) In several joints typical findings of OA, but not at OMT II (indicates stress b) Degenerative os trigonum b) Typical findings of OA b) Typical findings of OA b) Osteochondral lesion of talus b) Typical findings of OA; os tibiale externum; ; stress reaction anterior calcaneal process (2), stress reaction caput OMT II (2) Os trigonum syndrome (2) OA secondary to trimalleolar fracture Osteochondral lesion of talus (1) a) Os tibiale externum: low Accessory navicular Accessory navicular b) Os tibiale externum syndrome (1) b) Os tibiale externum syndrome (1) (better visualization of osteophytes and degenerative changes) (visualization of soft-tissue pathologies) and equal (visualization of ganglion cyst) (better visualization of exact borders of osteochondral lesion) (visualization of ganglion cyst) (superior anatomic depiction of accessory bone)
20 f 26 Pain in forefoot after a long hike 3 wk ago a) OMT III: intense ; sesamoid bone: intense OMT III: stress fracture (1); b) OMT III: BME, contrast enhancement sesamoid bone: stress and periosteal reaction; sesamoid bone reaction (2) (only retrospective): BME b) Periosteal reaction and callus formation OMT III, fracture line in sesamoid bone OMT III: stress fracture (1); sesamoid bone: fracture (1) 21 m 22 a) Talus: intense Pain in ankle joint b) Talus: PD fs intraosseous mass with Aneurysmatic bone cyst (1) without trauma cysts and fluid-fluid levels, low signal rim Unspecific osteolysis (1) on both T1 and T2w b) Osteolysis talus a) Lateral ankle joint: intense ; 22 m 74 enthesis of Achilles tendon: intense Pain at ankle and Focal OA of lateral ankle OA of lateral ankle joint (1); subtalar joint joint (1) posterior calcaneal spur (1) b) Lateral ankle joint: signs of b) typical findings of OA in ankle degeneration with BME joint; upper calcaneal spur metatarsophalangeal joint (MT), bone marrow edema (BME), tarsometatarsal joint (TM), Os metatarsale (OMT), osteoarthritis (OA), proton-density fat-saturated (PD fs) (display of fracture line in sesamoid bone) (more specific for aneurysmatic bone cyst (better visualization of osteophytes and degenerative changes)