 Good morning. My name is Dr. Harnit Khadir. I'm a third year PG resident in Maharashtra Malkindeshwar Institute of Medical Science and Research, Mulana. The topic I'm for paper is role of diffusion-mated MRI in musculoskeletal infections. Now we all know that musculoskeletal imaging is an important diagnostic and teaching tool for the healthcare providers in treatment of MSK pathologies. Now MSK infections can broadly be divided into the two types of infections that are superficial lesions, which includes tinoxinovitis, cellulitis and bursitis, and the deep lesions, which include pyomyositis, inacrotizing fissiitis, eftical tritis, or stytus, or stytus and ostomalitis. Now what is the role of diffusion-mated imaging in these MSK infections? Now diffusion-mated imaging is a part of a functional MR imaging, which can be incorporated into the routine non-contrast material, non-contrastinance MR imaging. Now diffusion-mated imaging, the advantage is that it does not require the additional timing as is required in the contrast imaging, so it can be easily added into the routine sequences. Now diffusion-mated imaging is based on the bronion motion of the water molecules caused by the tissue's microstructures. Now the apparent diffusion coefficient is a quantitative nature of this bronion movement. Low ADC value typically reflects the highly cellular micro environments in which the diffusion is restricted by the presence of the cell membranes, whereas a cellular regions allow free diffusion and results in elevated ADC values. Thus, with ADC mapping, one may drive useful quantitative information regarding the cellularity of our musculoskeletal lesions using a non-enhanced technique. The principle holds true in case of a highly cellular tumor such as the lymphomas and other hygrid malignancies. Contrary to this, in case of the abscesses, the restricted diffusion in a central necrotic area is due to the high viscosity bus bacteria and other proteinitious materials which are present there. Now the bone has a normally both the red and the yellow bone marrow with a significant amount of fat which is responsible for the high signal intensity on the MR images. Thus, the increased signal we see in the bone is not end because of the diffusion restriction, but enhancement of diffusion related to inflammatory edema and because of the cellularity. This enhancement in bone varies according to the pathology that is either because of the reactive edema, osteomalitis, introscious abscesses, necrotic bones with the highest signal obtained in case of the introscious abscess and least in case of the sequestrum. Now these are the list of some of the EDC values which are obtained in spectrum of the musculoskeletal infections. For osteomalitis, the value ranges from 1.1 to 1.4 for the soft tissue abscesses and for the introscious abscess, the EDC value corresponds to 0.6 to 1.1. For the pyomyocytus and the soft tissue edema, the values are slightly higher than that of the abscess values. That is from the 2 to 3 for the edema and from the pyomyocytus 1.5 to 1.8. Now aim and objective of our study was to study the role of diffusion wicked imaging in MSK infections and to correlate the MRI and DWR findings with a clinical outcome and clinical diagnosis. The study was carried out in the Department of Radio Diagnosis of Maharishi Mahal Khandeshwar Institute of Medical Sciences and Research, Mulana Ambala, and the sample size was 50 patients. Now the MRI scans were performed with a 1.5 Tesla MR machine, activated by Philips medical system. Now other relevant investigations were taken whenever it was such as the diagrams of the chest x-ray whenever there was a need for the x-rays. Now DWR images were obtained in the axial plane had 3 to 4 mm slice thickness, 1 mm intersection gap and the diffusion sensitizing gradient were applied in all the three orthogonal planes that is x-axis and y-axis and z-axis using the B values ranging from 0 to 100, 800. EDC maps are automatically calculated by the MRI machine software and were included in the sequence. When I required additional sequences were used like the T1 weighted images with or without fat suppression and contrast was also used. The MR findings and the diffusion weighted findings were correlated with the clinical findings and clinical outcome or the operator for the FNA findings. Now coming to the discussion, diagnosis of the skeletal infection remains a challenge, particularly when it's in the very early stages of the infection. Now the x-rays cannot rule out the very early stages of infection so we can use the CT, Cinti and MR are often performed to arrive with the diagnosis in the early cases of the infection. Now MR is extremely sensitive and gives us the accurate map of the anatomical distribution of the infection. On MRI the infected bone marrow, there's a low signal on T1 weighted images and high signal on the flare and the T2 weighted images. Now intramodality abscess and necrotic area should be enhanced with reactive bone marrow DEMA may also have some bone marrow findings. Diffusion weighted imaging shows normal bone as a dark signal with excellent negative predictive value. Thus it has to differentiate the reactive edema from the osteomalytus. The first related to introscess abscess formation and osteomalytus will have a greater bone diffusion with the relative distriction with the ADC value corresponding to 0.6 to 1.1 mm. On the other hand the reactive bone marrow DEMA will show mild diffusion weighted imaging signal enhancement with increased ADC value. Now the necrotic bone sequestrum air and de-vitalized tissue will not show any diffusion restriction and the corresponding ADC values will be high while ischemic but not the dead bone will show the increased diffusion weighted images and lower ADC value. This it can help differentiate between the active infection and the necrotic bone and the ischemic bone which cannot be otherwise differentiated. Now MRM staging imaging of the acute osteomalytus also utilizes the same sequences Peneco T1 and T2 weighted images, Stur and T2 facet images. The findings in the acute osteomalytus are outcome of medullary space edema and x-ray formation. The cases of acute osteomalytus the ADC value ranges between the 1.44 and it gives a low signal on T2 weighted images and high signal on T2 and Stur images. In our study the case of chronic osteomalytus gives a low to intermediate signal on both the T1 as well as T2 and Stur images. Though it was concluded in the study that the differentiation of chronic active from chronic inactive osteomalytus is quite problematic. Inactive disease there is presence of sequestrum, abscess, cloica and some periosteoflute collection. So now septic arthritis is a complex joint fluid which displays the intermediate or heterogeneous signal on T1 and T2 weighted images with synovial thickening as perisynovil edema. The non-infectious inflammatory synovitis may have similar findings on routine MR sequences. However, DWI can help differentiate the septic arthritis from other entities as the purulent and pus-like intraarticular fluid will show the restricted diffusion and lower ADC value. However, early stages of pyogenic arthritis may not show very low ADC values in the joint fluid because of minimal changes in the inflammatory cellular component in the viscosities. Conversely, in some cases underlying disease such as the RA or OA may have increased protein content and inflammatory cellular density and can cause the restricted diffusion. Now it may also play some role in differentiating septic arthritis from transient synovitis in pediatric patients. The case of inactive arthritis in our study had an average ADC value ranging from 1.7 and gives a low signal on T1 and heterogeneous to high signal on T2 weighted images. In case of the abscess, they have a low signal on T1 weighted images, high signal on T2 and star images. MR imaging is excellent not only in demonstrating the abscess but also to demonstrate the extent of involvement of the surrounding tissue. Abscess cavity demonstrates a low signal on T1 weighted images, high signal on T2 weighted images with enhancement of the walls after the contrast administrations. The walls are typically regular and thickening acute infections, regular 10 amp low signal on all the sequences with chronicity. Now in appropriate clinical science findings, these features are fairly specific for diagnosis of the abscess, however some necrophic tumors may have similar images in findings. By demonstrating the restricted diffusion in the center of abscess, DWI is helping differentiating these two hypotheses. Conversely, a tumor will show restricted diffusion in the walls as a result of high cellularity. So the cases of intravenous abscess in our study had the ADC value is the same as that in the Kumar in their study that is between 0.6 to 1.1. All the cellulitis is a clinical finding. MR is usually obtained to define the extent of the infections and to detect any underlying abscess. Thus that needs to be drained. On MR, the cellulitis appears skin technique that has a low signal intensity on T1 weighted images and high signal intensity on star and T2 fat set T2 weighted images. In situations where it cannot contrast cannot be administered like in case of the RFTs at the range or the patient is not very cooperative with medical long time. The differentiation of cellulitis from the subcutaneous edema can be very difficult. So DWI can be helping in demonstrating some restriction of the diffusion in cellulitis while simple subcutaneous edema with increased diffusion with increased diffusion. Now in case of tubercular arthritis, radiographs, tumultuous soft tissue, swelling, periarticula rostopunia and in this it's a particular minus. The advantage may be normal why the nerve depending on the stage unlike pyogenic arthritis. Articular cartilage destruction is minimally in early diseases. In the glaze series, articular destruction needs to reduce joint space and by losses. MR, in MR the soft tissue changes such as cyanovitis, joint effusion, bursitis, tinoxinovitis can better be demonstrated than the radiographs and periarticula bone marrow edema can also be seen in the MR which is not seen on the radiograph. The tubercular case gets a low signal intensity on T2 weighted image and a hyper intense signal on T2 weighted images with few of the cases associated with the joint effusion. In case of infectious tinoxinovitis, DWI may help differentiate the infectious tinoxinovitis from non-infectious causes by demonstrating a restricted diffusion due to viscous nature of the fluid that pass in the tendon sheet and the adjacent cellulitis. The fluid in the tendon sheet and infectious tinoxinovitis will be seen as a bright area on DWI, dark area on ADC mapping. Tendentary erosions are also nicely identified with bright signal untrition on DWI images. Now other help of findings from this study demonstrate the difference between the cellulitis and the subcutaneous edema. DWI can also help to differentiate muscle edema and the hematoma causes T2 shine through antiseptability artifacts. In our study we found that findings, finding reasons on DWI correlation with ADC map and conventional image can play a vital role in diagnosing MSK infection and can supplement the MR imaging in making the final diagnosis. Now this is an image obtained. There is a figure A shows a star image. We can see that there is an actual post-contrast backside P1 images. Now figure C and D corresponds to diffusion-mated images and the ADC images. Now in the figure E we can see that there is a large amount of joint diffusion or new diffusion is present and there is a summable technique and enhancement after the contrast enhancement. Now the same area which was showing the enhancement can also be underflown where I seem to restrict on the DWI images and the corresponding designable technique which is showing the enhancement is seen to restrict on the DWI images and the corresponding low value low signal on the ADC mapping. So the ADC value corresponds to 1.7 into 2 and 10.3 consistent with the clinical suspicion of the septic artifact. So we can see that the diffusion has almost the same binding as that after the contrast enhancement. Now this is a curve which is showing the diffusion-mated imaging. Number of diffusion-mated imaging findings in our study which corresponds to 84 percent of the patient which appears hyper on the diffusion-mated imaging. Now this is the corresponding ADC mapping. 84 percent of the were showing the hypo, hypo-intensive on the different ADC mapping. Now this graph corresponds to range of the ADC values which were mostly they were they were the corresponds to the low ADC value. Maximum values were between the 1.6 to 2 and almost less than two values were there. Now these are the DWI findings which were appearing hyper intense. Most of them cases include the acute osteomalytus, non-tubicular hip arthritis, sacroiliacus, tenus vitus, centrilytus, myositis all the infections conditions were appearing hyper on the DWI images with corresponding their ADC mapping which were appearing hypo intense on the ADC imaging. Now this is the average ADC value of the infections which were observed. Now in our study suggested the DWI supplements the conventional MR imaging in the area of musculoskeletal infections and act as a problem-solving tool in increasing lesions, conspicuity and help in differentiating among different but closely related entities and this helps in their accurate characterization. The knowledge of the four mentioned imaging findings with proper clinical history may help ensure the proper diagnosis and this helps in the proper treatment. Thank you so much.