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Appropriateness Criteria

Variant 1: 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 Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 9 0 0 0 0 0 0 0 0 11
References Study Quality
12 (21636263) 4
13 (20567730) 4
11 (28366223) 4
US foot Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 0 0 0 0 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 9 0 0 1 1 0 0 0 0
MRI foot without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 0 0 1 0 0 0 0 0
CT foot with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 10 0 1 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 10 0 1 0 0 0 0 0 0
CT foot without IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 10 0 1 0 0 0 0 0 0
3-phase bone scan foot Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 10 0 0 0 0 1 0 0 0
3-phase bone scan and WBC scan and sulfur colloid scan foot Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 9 0 0 0 1 1 0 0 0
3-phase bone scan and WBC scan foot Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 10 0 0 0 0 1 0 0 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 0 0 0 0 1 0 0 0
FDG-PET/CT whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 0 0 0 0 0 0 0 0
WBC scan and sulfur colloid scan foot Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 10 0 0 0 0 1 0 0 0
WBC scan foot Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 10 0 0 0 0 1 0 0 0
Variant 2: Soft-tissue swelling without ulcer. Suspected osteomyelitis or early neuropathic arthropathy changes of the foot in patients with diabetes mellitus. Additional imaging following radiographs.
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 1 0 0 0 0 0 1 1 8
References Study Quality
17 (24764120) 4
26 (23897135) 3
27 (21868781) 4
2 (28497161) 3
21 (16037509) 3
22 (19098186) 3
29 (15049523) 4
24 (18036160) 2
25 (10421237) 3
18 (15863990) 3
19 (18956147) 3
28 (8518119) 3
23 (17242312) M
20 (9169715) 3
MRI foot without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 1 0 0 1 1 1 4 3
References Study Quality
17 (24764120) 4
26 (23897135) 3
27 (21868781) 4
2 (28497161) 3
21 (16037509) 3
22 (19098186) 3
29 (15049523) 4
24 (18036160) 2
25 (10421237) 3
18 (15863990) 3
19 (18956147) 3
28 (8518119) 3
23 (17242312) M
20 (9169715) 3
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 2 0 0 0
References Study Quality
3 (27587513) 4
17 (24764120) 4
16 (18025514) 4
13 (20567730) 4
15 (29058098) 4
CT foot without IV contrast May be appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 1 0 2 1 5 2 0 0 0
References Study Quality
3 (27587513) 4
17 (24764120) 4
16 (18025514) 4
13 (20567730) 4
15 (29058098) 4
3-phase bone scan and WBC scan foot May be appropriate Limited ☢☢☢☢ 10-30 mSv 4 4 1 1 0 5 5 0 0 0 0
References Study Quality
32 (3171695) 3
33 (2341891) 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] 5 5 0 1 0 0 10 1 0 0 0
References Study Quality
51 (20851003) 2
47 (17138732) 2
48 (14523585) 3
49 (17146681) 3
50 (27560470) 3
FDG-PET/CT whole body May be appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 4 1 1 3 3 0 0 0 0
References Study Quality
41 (23905618) 4
42 (22801731) 1
44 (12766596) 3
45 (14990668) 4
39 (17460537) 2
40 (15680102) 2
43 (15750157) 3
46 (21934545) M
WBC scan foot May be appropriate Limited ☢☢☢☢ 10-30 mSv 4 4 1 1 2 2 5 0 0 0 0
References Study Quality
34 (16702459) 4
35 (3157204) 3
US foot Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 7 1 0 2 1 0 0 0 0
CT foot without and with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 11 0 1 0 0 0 0 0 0
References Study Quality
3 (27587513) 4
17 (24764120) 4
16 (18025514) 4
13 (20567730) 4
15 (29058098) 4
3-phase bone scan foot Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 6 0 1 2 1 1 0 0 0
References Study Quality
30 (26883537) 4
31 (10395336) 3
3-phase bone scan and WBC scan and sulfur colloid scan foot Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 2 2 4 3 0 2 2 0 1 0 0
References Study Quality
36 (9476948) 3
38 (26706230) 3
WBC scan and sulfur colloid scan foot Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 2 2 6 2 1 1 2 0 0 0 0
References Study Quality
37 (17127204) 4
36 (9476948) 3
Variant 3: Soft-tissue swelling with ulcer. Suspected osteomyelitis of the foot in patients with diabetes mellitus with or without neuropathic arthropathy. Additional imaging following radiographs.
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 1 0 0 0 0 0 1 2 7
References Study Quality
17 (24764120) 4
26 (23897135) 3
27 (21868781) 4
2 (28497161) 3
21 (16037509) 3
22 (19098186) 3
29 (15049523) 4
24 (18036160) 2
25 (10421237) 3
18 (15863990) 3
19 (18956147) 3
28 (8518119) 3
23 (17242312) M
20 (9169715) 3
MRI foot without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 1 0 0 1 0 2 4 3
References Study Quality
17 (24764120) 4
26 (23897135) 3
27 (21868781) 4
2 (28497161) 3
21 (16037509) 3
22 (19098186) 3
29 (15049523) 4
24 (18036160) 2
25 (10421237) 3
18 (15863990) 3
19 (18956147) 3
28 (8518119) 3
23 (17242312) M
20 (9169715) 3
CT foot with IV contrast May be appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 0 0 0 2 8 1 1 0 0
References Study Quality
3 (27587513) 4
17 (24764120) 4
16 (18025514) 4
13 (20567730) 4
15 (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 2 4 2 1 0 0
References Study Quality
3 (27587513) 4
17 (24764120) 4
16 (18025514) 4
13 (20567730) 4
15 (29058098) 4
3-phase bone scan foot May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv 5 5 1 0 4 1 0 1 2 3 0
References Study Quality
30 (26883537) 4
31 (10395336) 3
3-phase bone scan and WBC scan foot May be appropriate Limited ☢☢☢☢ 10-30 mSv 5 5 1 1 0 4 5 1 0 0 0
References Study Quality
30 (26883537) 4
31 (10395336) 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] 5 5 0 0 0 0 10 2 0 0 0
References Study Quality
51 (20851003) 2
47 (17138732) 2
48 (14523585) 3
49 (17146681) 3
50 (27560470) 3
FDG-PET/CT whole body May be appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 3 0 2 3 4 0 0 0 0
References Study Quality
41 (23905618) 4
42 (22801731) 1
44 (12766596) 3
45 (14990668) 4
39 (17460537) 2
40 (15680102) 2
43 (15750157) 3
46 (21934545) M
WBC scan foot May be appropriate Limited ☢☢☢☢ 10-30 mSv 4 4 1 1 1 3 5 0 0 0 0
References Study Quality
34 (16702459) 4
35 (3157204) 3
US foot Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 7 1 2 1 0 0 0 0 0
CT foot without and with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 10 0 1 0 0 0 0 0 0
References Study Quality
3 (27587513) 4
17 (24764120) 4
16 (18025514) 4
13 (20567730) 4
15 (29058098) 4
3-phase bone scan and WBC scan and sulfur colloid scan foot Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 2 2 6 2 0 1 2 0 1 0 0
References Study Quality
36 (9476948) 3
38 (26706230) 3
WBC scan and sulfur colloid scan foot Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 2 2 6 2 1 1 2 0 0 0 0
References Study Quality
37 (17127204) 4
36 (9476948) 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.