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Appropriateness Criteria

Variant 1: Adult. Suspected osteomyelitis of the foot in patients with diabetes mellitus. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography foot Usually appropriate Moderate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 9 0 1 0 0 0 0 0 0 13
References Study Quality
18 (21636263) 4
19 (20567730) 4
17 (28366223) 4
16 (32862106) Good
US foot Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 3 1 0 1 0 0 0 0
MRI foot without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 1 0 0 2 1 0 0 0
MRI foot without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 0 1 0 1 0 0 0 1
CT foot with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 12 2 0 0 0 0 0 0 0
CT foot without and with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 11 1 0 0 1 1 0 0 0
CT foot without IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 12 0 0 0 0 1 0 0 1
3-phase bone scan foot Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 10 1 1 1 0 0 1 0 0
3-phase bone scan and WBC scan and sulfur colloid scan foot Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 10 2 1 0 0 0 0 1 0
3-phase bone scan and WBC scan foot Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 10 2 1 0 0 0 0 1 0
3-phase bone scan and WBC scan with SPECT or SPECT/CT foot Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 2 1 0 0 0 0 0 1
FDG-PET/CT whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 1 0 0 0 0 2 0 0
WBC scan and sulfur colloid scan foot Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 10 1 1 0 1 1 0 0 0
WBC scan foot Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 10 0 2 0 2 0 0 0 0
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 SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI foot without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 2 0 1 0 11
References Study Quality
63 (8518119) 3
62 (10421237) 3
61 (18036160) 2
60 (37123500) 3
59 (19098186) 3
58 (34145466) 4
57 (16037509) 3
56 (9169715) 3
55 (17242312) M
54 (32130445) 3
53 (18956147) 3
52 (15863990) 3
6 (18611152) M
2 (28497161) 3
MRI foot without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 1 0 1 4 8
References Study Quality
64 (31463805) 2
62 (10421237) 3
61 (18036160) 2
60 (37123500) 3
59 (19098186) 3
58 (34145466) 4
57 (16037509) 3
56 (9169715) 3
55 (17242312) M
54 (32130445) 3
53 (18956147) 3
52 (15863990) 3
6 (18611152) M
2 (28497161) 3
CT foot with IV contrast May be appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 6 6 0 1 0 1 2 4 5 0 1
References Study Quality
41 (18025514) 4
40 (27587513) 4
39 (24764120) 4
38 (29058098) 4
CT foot without IV contrast May be appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 2 0 1 0 10 1 0 0 0
References Study Quality
40 (27587513) 4
39 (24764120) 4
38 (29058098) 4
3-phase bone scan foot May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv 5 5 3 3 4 0 1 3 0 0 0
References Study Quality
6 (18611152) M
37 (10395336) 3
36 (2646871) 2
35 (1727365) 4
34 (1872240) 3
FDG-PET/CT whole body May be appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 6 0 0 5 2 0 1 0 0
References Study Quality
46 (32486304) 2
45 (23906976) Good
44 (28733376) Good
43 (15750157) 3
42 (22801731) 1
29 (16264122) Inadequate
US foot Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 2 4 7 1 0 0 0 0 0
References Study Quality
65 (37950713) 2
Image-guided biopsy foot Usually not appropriate Strong Varies Varies 1 1 9 0 2 1 2 0 0 0 0
References Study Quality
51 (33739950) 2
50 (33134407) Good
49 (30778640) 4
48 (31322951) 4
47 (36905125) 4
CT foot without and with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 9 1 3 1 0 0 0 0 0
References Study Quality
41 (18025514) 4
40 (27587513) 4
39 (24764120) 4
38 (29058098) 4
3-phase bone scan and WBC scan and sulfur colloid scan foot Usually not appropriate Strong ☢☢☢☢ 10-30 mSv 3 3 3 3 3 2 3 0 0 0 0
References Study Quality
24 (1572113) 3
23 (27390160) 4
22 (20851003) 2
21 (26706230) 3
20 (9476948) 3
3-phase bone scan and WBC scan foot Usually not appropriate Strong ☢☢☢☢ 10-30 mSv 3 3 5 2 3 4 0 0 0 0 0
References Study Quality
29 (16264122) Inadequate
28 (8821280) 3
27 (9473260) 2
26 (2341891) 3
25 (3171695) 3
3-phase bone scan and WBC scan with SPECT or SPECT/CT foot Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 2 4 2 1 2 0 0 0
References Study Quality
22 (20851003) 2
33 (27560470) 3
32 (17146681) 3
31 (14523585) 3
30 (17138732) 2
WBC scan and sulfur colloid scan foot Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 2 2 7 1 3 0 3 0 0 0 0
References Study Quality
66 (17127204) 4
24 (1572113) 3
23 (27390160) 4
21 (26706230) 3
20 (9476948) 3
WBC scan foot Usually not appropriate Strong ☢☢☢☢ 10-30 mSv 2 2 7 1 3 1 2 0 0 0 0
References Study Quality
68 (16702459) 4
67 (3157204) 3
44 (28733376) Good
34 (1872240) 3
24 (1572113) 3
Variant 3: Adult. Radiographs positive for osteomyelitis of the foot in patients with diabetes mellitus. Next imaging study for pretreatment planning.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI foot without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 1 1 0 2 10
References Study Quality
71 (11756124) 2
70 (30136224) 4
63 (8518119) 3
62 (10421237) 3
61 (18036160) 2
60 (37123500) 3
59 (19098186) 3
58 (34145466) 4
57 (16037509) 3
56 (9169715) 3
55 (17242312) M
54 (32130445) 3
53 (18956147) 3
52 (15863990) 3
6 (18611152) M
2 (28497161) 3
MRI foot without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 1 0 2 1 4 6
References Study Quality
70 (30136224) 4
62 (10421237) 3
61 (18036160) 2
60 (37123500) 3
59 (19098186) 3
58 (34145466) 4
57 (16037509) 3
56 (9169715) 3
55 (17242312) M
54 (32130445) 3
53 (18956147) 3
52 (15863990) 3
6 (18611152) M
2 (28497161) 3
Image-guided biopsy foot May be appropriate Strong Varies Varies 5 5 0 0 0 4 7 2 1 0 0
References Study Quality
51 (33739950) 2
50 (33134407) Good
49 (30778640) 4
48 (31322951) 4
47 (36905125) 4
CT foot with IV contrast May be appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 6 6 0 1 0 2 1 5 4 0 1
References Study Quality
41 (18025514) 4
40 (27587513) 4
39 (24764120) 4
38 (29058098) 4
CT foot without IV contrast May be appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 1 0 1 5 7 0 0 0 0
References Study Quality
40 (27587513) 4
39 (24764120) 4
38 (29058098) 4
14 (36820925) 2
3-phase bone scan and WBC scan with SPECT or SPECT/CT foot May be appropriate (Disagreement) Expert Opinion ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 5 3 1 1 1 3 0 0 0
References Study Quality
69 (38649465) 2
33 (27560470) 3
32 (17146681) 3
31 (14523585) 3
30 (17138732) 2
22 (20851003) 2
WBC scan foot May be appropriate Strong ☢☢☢☢ 10-30 mSv 5 5 1 1 2 3 5 1 1 0 0
References Study Quality
68 (16702459) 4
67 (3157204) 3
44 (28733376) Good
34 (1872240) 3
24 (1572113) 3
US foot Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 3 2 4 3 1 1 0 0 0
References Study Quality
65 (37950713) 2
CT foot without and with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 2 2 6 2 4 2 0 0 0 0 0
References Study Quality
41 (18025514) 4
40 (27587513) 4
39 (24764120) 4
38 (29058098) 4
14 (36820925) 2
3-phase bone scan foot Usually not appropriate Limited ☢☢☢ 1-10 mSv 2 2 5 3 6 0 0 0 0 0 0
References Study Quality
37 (10395336) 3
36 (2646871) 2
35 (1727365) 4
34 (1872240) 3
6 (18611152) M
3-phase bone scan and WBC scan and sulfur colloid scan foot Usually not appropriate Strong ☢☢☢☢ 10-30 mSv 2 2 5 5 3 0 1 0 0 0 0
References Study Quality
24 (1572113) 3
23 (27390160) 4
22 (20851003) 2
21 (26706230) 3
20 (9476948) 3
3-phase bone scan and WBC scan foot Usually not appropriate Strong ☢☢☢☢ 10-30 mSv 2 2 5 5 1 3 0 0 0 0 0
References Study Quality
29 (16264122) Inadequate
28 (8821280) 3
27 (9473260) 2
26 (2341891) 3
25 (3171695) 3
FDG-PET/CT whole body Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 3 4 0 0 0 0 0 0
References Study Quality
46 (32486304) 2
45 (23906976) Good
44 (28733376) Good
43 (15750157) 3
42 (22801731) 1
29 (16264122) Inadequate
WBC scan and sulfur colloid scan foot Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 3 3 3 3 4 1 3 0 0 0 0
References Study Quality
66 (17127204) 4
24 (1572113) 3
23 (27390160) 4
21 (26706230) 3
20 (9476948) 3
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 SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI foot without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 1 0 2 2 4 2 3
References Study Quality
77 (30660474) 3
76 (32040604) 4
63 (8518119) 3
60 (37123500) 3
59 (19098186) 3
58 (34145466) 4
57 (16037509) 3
54 (32130445) 3
53 (18956147) 3
52 (15863990) 3
MRI foot without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 1 0 1 3 5 2 2
References Study Quality
77 (30660474) 3
76 (32040604) 4
60 (37123500) 3
59 (19098186) 3
58 (34145466) 4
57 (16037509) 3
54 (32130445) 3
53 (18956147) 3
52 (15863990) 3
3-phase bone scan and WBC scan with SPECT or SPECT/CT foot Usually appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 1 0 2 4 2 1 4
References Study Quality
33 (27560470) 3
32 (17146681) 3
31 (14523585) 3
30 (17138732) 2
26 (2341891) 3
25 (3171695) 3
22 (20851003) 2
CT foot with IV contrast May be appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 0 0 0 1 8 4 1 0 0
References Study Quality
41 (18025514) 4
40 (27587513) 4
39 (24764120) 4
38 (29058098) 4
19 (20567730) 4
14 (36820925) 2
CT foot without IV contrast May be appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 6 6 0 0 0 2 4 7 1 0 0
References Study Quality
40 (27587513) 4
39 (24764120) 4
38 (29058098) 4
19 (20567730) 4
14 (36820925) 2
3-phase bone scan and WBC scan and sulfur colloid scan foot May be appropriate Strong ☢☢☢☢ 10-30 mSv 6 6 0 0 1 0 5 2 1 2 3
References Study Quality
24 (1572113) 3
23 (27390160) 4
22 (20851003) 2
21 (26706230) 3
20 (9476948) 3
3-phase bone scan and WBC scan foot May be appropriate Strong ☢☢☢☢ 10-30 mSv 6 6 0 0 1 1 3 4 1 1 3
References Study Quality
29 (16264122) Inadequate
28 (8821280) 3
27 (9473260) 2
26 (2341891) 3
25 (3171695) 3
WBC scan and sulfur colloid scan foot May be appropriate Limited ☢☢☢☢ 10-30 mSv 5 5 0 0 0 2 8 1 1 1 1
References Study Quality
66 (17127204) 4
24 (1572113) 3
23 (27390160) 4
21 (26706230) 3
20 (9476948) 3
US foot Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 5 2 5 2 0 0 0 0 0
References Study Quality
65 (37950713) 2
Image-guided biopsy foot Usually not appropriate Strong Varies Varies 2 2 7 0 2 1 3 1 0 0 0
References Study Quality
51 (33739950) 2
50 (33134407) Good
49 (30778640) 4
48 (31322951) 4
47 (36905125) 4
CT foot without and with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 2 2 6 3 2 3 0 0 0 0 0
References Study Quality
41 (18025514) 4
40 (27587513) 4
39 (24764120) 4
38 (29058098) 4
19 (20567730) 4
14 (36820925) 2
3-phase bone scan foot Usually not appropriate Limited ☢☢☢ 1-10 mSv 2 2 6 2 3 0 3 0 0 0 0
References Study Quality
37 (10395336) 3
36 (2646871) 2
35 (1727365) 4
34 (1872240) 3
6 (18611152) M
FDG-PET/CT whole body Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 2 5 0 0 0 0 0 0
References Study Quality
75 (21934545) M
74 (14990668) 4
73 (12766596) 3
46 (32486304) 2
45 (23906976) Good
44 (28733376) Good
43 (15750157) 3
42 (22801731) 1
29 (16264122) Inadequate
WBC scan foot Usually not appropriate Strong ☢☢☢☢ 10-30 mSv 2 2 6 2 1 2 3 0 0 0 0
References Study Quality
68 (16702459) 4
67 (3157204) 3
44 (28733376) Good
34 (1872240) 3
24 (1572113) 3
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 SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI foot without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 1 2 2 1 4 4
References Study Quality
77 (30660474) 3
76 (32040604) 4
63 (8518119) 3
60 (37123500) 3
59 (19098186) 3
58 (34145466) 4
57 (16037509) 3
54 (32130445) 3
53 (18956147) 3
52 (15863990) 3
MRI foot without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 1 0 1 5 2 3 2
References Study Quality
77 (30660474) 3
76 (32040604) 4
60 (37123500) 3
59 (19098186) 3
58 (34145466) 4
57 (16037509) 3
54 (32130445) 3
53 (18956147) 3
52 (15863990) 3
Image-guided biopsy foot May be appropriate Strong Varies Varies 5 5 0 0 0 2 7 5 0 0 0
References Study Quality
51 (33739950) 2
50 (33134407) Good
49 (30778640) 4
48 (31322951) 4
47 (36905125) 4
CT foot with IV contrast May be appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 0 0 0 1 9 1 3 0 0
References Study Quality
41 (18025514) 4
40 (27587513) 4
39 (24764120) 4
38 (29058098) 4
19 (20567730) 4
14 (36820925) 2
CT foot without IV contrast May be appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 0 0 1 1 7 3 1 1 0
References Study Quality
40 (27587513) 4
39 (24764120) 4
38 (29058098) 4
19 (20567730) 4
14 (36820925) 2
3-phase bone scan and WBC scan and sulfur colloid scan foot May be appropriate Strong ☢☢☢☢ 10-30 mSv 6 6 0 0 1 0 5 3 0 2 3
References Study Quality
24 (1572113) 3
23 (27390160) 4
22 (20851003) 2
21 (26706230) 3
20 (9476948) 3
3-phase bone scan and WBC scan foot May be appropriate Strong ☢☢☢☢ 10-30 mSv 6 6 0 0 1 1 4 4 0 1 3
References Study Quality
29 (16264122) Inadequate
28 (8821280) 3
27 (9473260) 2
26 (2341891) 3
25 (3171695) 3
3-phase bone scan and WBC scan with SPECT or SPECT/CT foot May be appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 1 1 2 5 1 1 3
References Study Quality
69 (38649465) 2
33 (27560470) 3
32 (17146681) 3
31 (14523585) 3
30 (17138732) 2
22 (20851003) 2
WBC scan and sulfur colloid scan foot May be appropriate Limited ☢☢☢☢ 10-30 mSv 6 6 0 0 1 1 4 4 1 0 3
References Study Quality
66 (17127204) 4
24 (1572113) 3
23 (27390160) 4
21 (26706230) 3
20 (9476948) 3
US foot Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 4 2 4 3 1 0 0 0 0
References Study Quality
65 (37950713) 2
CT foot without and with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 2 2 6 3 5 0 0 0 0 0 0
References Study Quality
41 (18025514) 4
40 (27587513) 4
39 (24764120) 4
38 (29058098) 4
19 (20567730) 4
14 (36820925) 2
3-phase bone scan foot Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 3 2 5 1 3 0 0 0 0
References Study Quality
37 (10395336) 3
36 (2646871) 2
35 (1727365) 4
34 (1872240) 3
6 (18611152) M
FDG-PET/CT whole body Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 2 3 2 0 0 0 0 0
References Study Quality
75 (21934545) M
74 (14990668) 4
73 (12766596) 3
72 (15680102) 2
46 (32486304) 2
45 (23906976) Good
44 (28733376) Good
43 (15750157) 3
42 (22801731) 1
29 (16264122) Inadequate
WBC scan foot Usually not appropriate Strong ☢☢☢☢ 10-30 mSv 3 3 5 2 2 2 3 0 0 0 0
References Study Quality
68 (16702459) 4
67 (3157204) 3
44 (28733376) Good
34 (1872240) 3
24 (1572113) 3
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.