Suspected Osteomyelitis of the Foot in Patients with Diabetes Mellitus

Variant: 1 Adult. Suspected osteomyelitis of the foot in patients with diabetes mellitus. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
Radiography foot	Usually Appropriate	☢
US foot	Usually Not Appropriate	O
MRI foot without and with IV contrast	Usually Not Appropriate	O
MRI foot without IV contrast	Usually Not Appropriate	O
CT foot with IV contrast	Usually Not Appropriate	☢
CT foot without and with IV contrast	Usually Not Appropriate	☢
CT foot without IV contrast	Usually Not Appropriate	☢
3-phase bone scan foot	Usually Not Appropriate	☢☢☢
3-phase bone scan and WBC scan and sulfur colloid scan foot	Usually Not Appropriate	☢☢☢☢
3-phase bone scan and WBC scan foot	Usually Not Appropriate	☢☢☢☢
3-phase bone scan and WBC scan with SPECT or SPECT/CT foot	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT whole body	Usually Not Appropriate	☢☢☢☢
WBC scan and sulfur colloid scan foot	Usually Not Appropriate	☢☢☢☢
WBC scan foot	Usually Not Appropriate	☢☢☢☢

Variant: 2 Adult. Suspected osteomyelitis of the foot in patients with diabetes mellitus. Initial radiographs negative or indeterminate for osteomyelitis. Next imaging study.

Procedure	Appropriateness Category	Relative Radiation Level
MRI foot without and with IV contrast	Usually Appropriate	O
MRI foot without IV contrast	Usually Appropriate	O
CT foot with IV contrast	May Be Appropriate	☢
CT foot without IV contrast	May Be Appropriate	☢
3-phase bone scan foot	May Be Appropriate (Disagreement)	☢☢☢
FDG-PET/CT whole body	May Be Appropriate	☢☢☢☢
US foot	Usually Not Appropriate	O
Image-guided biopsy foot	Usually Not Appropriate	Varies
CT foot without and with IV contrast	Usually Not Appropriate	☢
3-phase bone scan and WBC scan and sulfur colloid scan foot	Usually Not Appropriate	☢☢☢☢
3-phase bone scan and WBC scan foot	Usually Not Appropriate	☢☢☢☢
3-phase bone scan and WBC scan with SPECT or SPECT/CT foot	Usually Not Appropriate	☢☢☢☢
WBC scan and sulfur colloid scan foot	Usually Not Appropriate	☢☢☢☢
WBC scan foot	Usually Not Appropriate	☢☢☢☢

Variant: 3 Adult. Radiographs positive for osteomyelitis of the foot in patients with diabetes mellitus. Next imaging study for pretreatment planning.

Procedure	Appropriateness Category	Relative Radiation Level
MRI foot without and with IV contrast	Usually Appropriate	O
MRI foot without IV contrast	Usually Appropriate	O
Image-guided biopsy foot	May Be Appropriate	Varies
CT foot with IV contrast	May Be Appropriate	☢
CT foot without IV contrast	May Be Appropriate	☢
3-phase bone scan and WBC scan with SPECT or SPECT/CT foot	May Be Appropriate (Disagreement)	☢☢☢☢
WBC scan foot	May Be Appropriate	☢☢☢☢
US foot	Usually Not Appropriate	O
CT foot without and with IV contrast	Usually Not Appropriate	☢
3-phase bone scan foot	Usually Not Appropriate	☢☢☢
3-phase bone scan and WBC scan and sulfur colloid scan foot	Usually Not Appropriate	☢☢☢☢
3-phase bone scan and WBC scan foot	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT whole body	Usually Not Appropriate	☢☢☢☢
WBC scan and sulfur colloid scan foot	Usually Not Appropriate	☢☢☢☢

Variant: 4 Adult. Suspected osteomyelitis of the foot in patients with diabetes mellitus and metal instrumentation in the foot. Initial radiographs negative or indeterminate for osteomyelitis. Next imaging study.

Procedure	Appropriateness Category	Relative Radiation Level
MRI foot without and with IV contrast	Usually Appropriate	O
MRI foot without IV contrast	Usually Appropriate	O
3-phase bone scan and WBC scan with SPECT or SPECT/CT foot	Usually Appropriate	☢☢☢☢
CT foot with IV contrast	May Be Appropriate	☢
CT foot without IV contrast	May Be Appropriate	☢
3-phase bone scan and WBC scan and sulfur colloid scan foot	May Be Appropriate	☢☢☢☢
3-phase bone scan and WBC scan foot	May Be Appropriate	☢☢☢☢
WBC scan and sulfur colloid scan foot	May Be Appropriate	☢☢☢☢
US foot	Usually Not Appropriate	O
Image-guided biopsy foot	Usually Not Appropriate	Varies
CT foot without and with IV contrast	Usually Not Appropriate	☢
3-phase bone scan foot	Usually Not Appropriate	☢☢☢
FDG-PET/CT whole body	Usually Not Appropriate	☢☢☢☢
WBC scan foot	Usually Not Appropriate	☢☢☢☢

Variant: 5 Adult. Radiographs positive for osteomyelitis of the foot in patients with diabetes mellitus and metal instrumentation in the foot. Next imaging study for pretreatment planning.

Procedure	Appropriateness Category	Relative Radiation Level
MRI foot without and with IV contrast	Usually Appropriate	O
MRI foot without IV contrast	Usually Appropriate	O
Image-guided biopsy foot	May Be Appropriate	Varies
CT foot with IV contrast	May Be Appropriate	☢
CT foot without IV contrast	May Be Appropriate	☢
3-phase bone scan and WBC scan and sulfur colloid scan foot	May Be Appropriate	☢☢☢☢
3-phase bone scan and WBC scan foot	May Be Appropriate	☢☢☢☢
3-phase bone scan and WBC scan with SPECT or SPECT/CT foot	May Be Appropriate	☢☢☢☢
WBC scan and sulfur colloid scan foot	May Be Appropriate	☢☢☢☢
US foot	Usually Not Appropriate	O
CT foot without and with IV contrast	Usually Not Appropriate	☢
3-phase bone scan foot	Usually Not Appropriate	☢☢☢
FDG-PET/CT whole body	Usually Not Appropriate	☢☢☢☢
WBC scan foot	Usually Not Appropriate	☢☢☢☢

Jonathan C. Baker, MD^a, Benjamin E. Northrup, MD^b, Shivani Ahlawat, MD^c, Hailey Allen, MD^d, Geneve Allison, MD^e, James Banks, MD^f, Matthew P. Borloz, MD^g, Murthy R. Chamarthy, MD^h, Hillary W. Garner, MDⁱ, Christopher Edward Gross, MD^j, Jinel A. Scott, MD, MBA^k, Timothy Switaj, MD^l, Jennifer Zreloff, MD^m, Daniel E. Wessell, MD, PhDⁿ

Summary of Literature Review

Introduction/Background

Special Imaging Considerations

Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

There are procedures that are equivalent alternatives (ie, only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

There are complementary procedures (ie, more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).

Discussion of Procedures by Variant

Variant 1: Adult. Suspected osteomyelitis of the foot in patients with diabetes mellitus. Initial imaging.

Variant 1: Adult. Suspected osteomyelitis of the foot in patients with diabetes mellitus. Initial imaging.
A. 3-Phase Bone Scan and WBC Scan and Sulfur Colloid Scan Foot

Variant 1: Adult. Suspected osteomyelitis of the foot in patients with diabetes mellitus. Initial imaging.
B. 3-Phase Bone Scan and WBC Scan Foot

Variant 1: Adult. Suspected osteomyelitis of the foot in patients with diabetes mellitus. Initial imaging.
C. 3-Phase Bone Scan and WBC Scan with SPECT or SPECT/CT Foot

Variant 1: Adult. Suspected osteomyelitis of the foot in patients with diabetes mellitus. Initial imaging.
D. 3-Phase Bone Scan Foot

Variant 1: Adult. Suspected osteomyelitis of the foot in patients with diabetes mellitus. Initial imaging.
E. CT Foot With IV Contrast

Variant 1: Adult. Suspected osteomyelitis of the foot in patients with diabetes mellitus. Initial imaging.
F. CT Foot Without and With IV Contrast

Variant 1: Adult. Suspected osteomyelitis of the foot in patients with diabetes mellitus. Initial imaging.
G. CT Foot Without IV Contrast

Variant 1: Adult. Suspected osteomyelitis of the foot in patients with diabetes mellitus. Initial imaging.
H. FDG-PET/CT Whole Body

Variant 1: Adult. Suspected osteomyelitis of the foot in patients with diabetes mellitus. Initial imaging.
I. MRI Foot Without and With IV Contrast

Variant 1: Adult. Suspected osteomyelitis of the foot in patients with diabetes mellitus. Initial imaging.
J. MRI Foot Without IV Contrast

Variant 1: Adult. Suspected osteomyelitis of the foot in patients with diabetes mellitus. Initial imaging.
K. Radiography Foot

Variant 1: Adult. Suspected osteomyelitis of the foot in patients with diabetes mellitus. Initial imaging.
L. US Foot

Variant 1: Adult. Suspected osteomyelitis of the foot in patients with diabetes mellitus. Initial imaging.
M. WBC Scan and Sulfur Colloid Scan Foot

Variant 1: Adult. Suspected osteomyelitis of the foot in patients with diabetes mellitus. Initial imaging.
N. WBC Scan Foot

Variant 2: Adult. Suspected osteomyelitis of the foot in patients with diabetes mellitus. Initial radiographs negative or indeterminate for osteomyelitis. Next imaging study.

Variant 2: Adult. Suspected osteomyelitis of the foot in patients with diabetes mellitus. Initial radiographs negative or indeterminate for osteomyelitis. Next imaging study.
A. 3-Phase Bone Scan and WBC Scan and Sulfur Colloid Scan Foot

Variant 2: Adult. Suspected osteomyelitis of the foot in patients with diabetes mellitus. Initial radiographs negative or indeterminate for osteomyelitis. Next imaging study.
C. 3-Phase Bone Scan and WBC Scan with SPECT or SPECT/CT Foot

Variant 2: Adult. Suspected osteomyelitis of the foot in patients with diabetes mellitus. Initial radiographs negative or indeterminate for osteomyelitis. Next imaging study.
L. US Foot

Variant 2: Adult. Suspected osteomyelitis of the foot in patients with diabetes mellitus. Initial radiographs negative or indeterminate for osteomyelitis. Next imaging study.
N. WBC Scan Foot

Variant 3: Adult. Radiographs positive for osteomyelitis of the foot in patients with diabetes mellitus. Next imaging study for pretreatment planning.

Variant 3: Adult. Radiographs positive for osteomyelitis of the foot in patients with diabetes mellitus. Next imaging study for pretreatment planning.
A. 3-Phase Bone Scan and WBC Scan and Sulfur Colloid Scan Foot

Variant 3: Adult. Radiographs positive for osteomyelitis of the foot in patients with diabetes mellitus. Next imaging study for pretreatment planning.
B. 3-Phase Bone Scan and WBC Scan Foot

Variant 3: Adult. Radiographs positive for osteomyelitis of the foot in patients with diabetes mellitus. Next imaging study for pretreatment planning.
C. 3-Phase Bone Scan and WBC Scan with SPECT or SPECT/CT Foot

Variant 3: Adult. Radiographs positive for osteomyelitis of the foot in patients with diabetes mellitus. Next imaging study for pretreatment planning.
D. 3-Phase Bone Scan Foot

Variant 3: Adult. Radiographs positive for osteomyelitis of the foot in patients with diabetes mellitus. Next imaging study for pretreatment planning.
E. CT Foot With IV Contrast

Variant 3: Adult. Radiographs positive for osteomyelitis of the foot in patients with diabetes mellitus. Next imaging study for pretreatment planning.
F. CT Foot Without and With IV Contrast

Variant 3: Adult. Radiographs positive for osteomyelitis of the foot in patients with diabetes mellitus. Next imaging study for pretreatment planning.
G. CT Foot Without IV Contrast

Variant 3: Adult. Radiographs positive for osteomyelitis of the foot in patients with diabetes mellitus. Next imaging study for pretreatment planning.
H. FDG-PET/CT Whole Body

Variant 3: Adult. Radiographs positive for osteomyelitis of the foot in patients with diabetes mellitus. Next imaging study for pretreatment planning.
I. Image-Guided Biopsy Foot

Variant 3: Adult. Radiographs positive for osteomyelitis of the foot in patients with diabetes mellitus. Next imaging study for pretreatment planning.
J. MRI Foot Without and With IV Contrast

Variant 3: Adult. Radiographs positive for osteomyelitis of the foot in patients with diabetes mellitus. Next imaging study for pretreatment planning.
K. MRI Foot Without IV Contrast

Variant 3: Adult. Radiographs positive for osteomyelitis of the foot in patients with diabetes mellitus. Next imaging study for pretreatment planning.
L. US Foot

Variant 3: Adult. Radiographs positive for osteomyelitis of the foot in patients with diabetes mellitus. Next imaging study for pretreatment planning.
M. WBC Scan and Sulfur Colloid Scan Foot

Variant 3: Adult. Radiographs positive for osteomyelitis of the foot in patients with diabetes mellitus. Next imaging study for pretreatment planning.
N. WBC Scan Foot

Variant 4: Adult. Suspected osteomyelitis of the foot in patients with diabetes mellitus and metal instrumentation in the foot. Initial radiographs negative or indeterminate for osteomyelitis. Next imaging study.

Variant 5: Radiographs positive for osteomyelitis of the foot in patients with diabetes mellitus and metal instrumentation in the foot. Next imaging study for pretreatment planning.

Variant 5: Radiographs positive for osteomyelitis of the foot in patients with diabetes mellitus and metal instrumentation in the foot. Next imaging study for pretreatment planning.
A. 3-Phase Bone Scan and WBC Scan and Sulfur Colloid Scan Foot

Variant 5: Radiographs positive for osteomyelitis of the foot in patients with diabetes mellitus and metal instrumentation in the foot. Next imaging study for pretreatment planning.
C. 3-Phase Bone Scan and WBC Scan With SPECT or SPECT/CT Foot

Summary of Highlights

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Gender Equality and Inclusivity Clause

The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”

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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.