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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Hackett DJ, Rothenberg AC, Chen AF, et al. The economic significance of orthopaedic infections. J Am Acad Orthop Surg 2015;23 Suppl:S1-7. Review/Other-Dx N/A To discuss the growing economic burden of orthopaedic infections on the American healthcare system. No results stated in abstract. 4
2. Hayeri MR, Ziai P, Shehata ML, Teytelboym OM, Huang BK. Soft-Tissue Infections and Their Imaging Mimics: From Cellulitis to Necrotizing Fasciitis. [Review]. Radiographics. 36(6):1888-1910, 2016 Oct. Review/Other-Dx N/A To review the spectrum of soft-tissue infections using a systematic anatomic compartment approach. No results stated in abstract. 4
3. Turecki MB, Taljanovic MS, Stubbs AY, et al. Imaging of musculoskeletal soft tissue infections. Skeletal Radiol. 2010;39(10):957-971. Review/Other-Dx N/A To illustrate representative images of superficial and deep soft tissue infections such as infectious cellulitis, superficial and deep fasciitis, including the necrotizing fasciitis, pyomyositis/soft tissue abscess, septic bursitis and tenosynovitis on different imaging modalities, with emphasis on MRI. Typical histopathologic findings of soft tissue infections are also presented. MRI is the imaging modality of choice in the evaluation of soft tissue infections. CT, US, radiography and nuclear medicine studies are considered ancillary. 4
4. Yadavalli S. Radiologic Evaluation of Musculoskeletal Soft Tissue Infections: A Pictorial Review. Current Radiology Reports 2015;3:40. Review/Other-Dx N/A To review various types of musculoskeletal soft tissue infections that may be encountered and their imaging features utilizing different imaging modalities, including radiography, computed tomography, ultrasound and magnetic resonance imaging. No results stated in abstract. 4
5. Schmitt SK.. Osteomyelitis. [Review]. Infect Dis Clin North Am. 31(2):325-338, 2017 06. Review/Other-Dx N/A To review the recognition and management of osteomyelitis . No results stated in abstract. 4
6. Simpfendorfer CS.. Radiologic Approach to Musculoskeletal Infections. [Review]. Infect Dis Clin North Am. 31(2):299-324, 2017 06. Review/Other-Dx N/A To review the individual imaging modalities and discusses how specific musculoskeletal infections should be approached from an imaging perspective. No results stated in abstract. 4
7. Palestro CJ.. Radionuclide Imaging of Musculoskeletal Infection: A Review. [Review]. J Nucl Med. 57(9):1406-12, 2016 09. Review/Other-Dx N/A To review the various radiopharmaceuticals used in the diagnostic workup of patients suspected of having musculoskeletal infection. No results stated in abstract. 4
8. Chan BY, Crawford AM, Kobes PH, et al. Septic Arthritis: An Evidence-Based Review of Diagnosis and Image-Guided Aspiration. AJR Am J Roentgenol 2020;215:568-81. Review/Other-Dx N/A To equip radiologists to discuss and interpret findings obtained with various imaging modalities, guide patient selection for percutaneous aspiration, and safely perform arthrocentesis to assess for infection in both native and prosthetic joints. No results stated in abstract. 4
9. Porrino J, Richardson ML, Flaherty E, et al. Septic Arthritis and Joint Aspiration: The Radiologist's Role in Image-Guided Aspiration for Suspected Septic Arthritis. Semin Roentgenol 2019;54:177-89. Review/Other-Dx 249 SSR members (Society of Skeletal Radiology) To poll those practicing musculoskeletal (MSK) radiology in both the private practice and academic realm with regards to the decision-making process related to joint aspiration for suspected septic arthritis. Radiologists are mixed with regards to how commonly encountered variables alter their decision to perform an aspiration. Most notably, how to proceed when inflamed soft tissue overlies the needle path is not clear based on results. 4
10. Hansford BG, Stacy GS. Musculoskeletal aspiration procedures. Semin Intervent Radiol 2012;29:270-85. Review/Other-Dx N/A To discuss the appropriate indications, contraindications, and general technique for accessing the major joints via imaging guidance. For each joint, we discuss pertinent anatomy, appropriate imaging modalities, and preferred approaches to gaining intra-articular access. Additionally, the article discusses some of the more frequently encountered juxta-articular and intramuscular fluid collections that can be accessed and aspirated via percutaneous intervention, with mention of the importance of recognizing extremity sarcomas that can mimic these benign collections. One of the most commonly performed image-guided MSK interventions is the diagnostic and therapeutic percutaneous aspiration and drainage of multiple types of intra-articular, juxta-articular, and intramuscular pathologic fluid collections. These procedures may be performed under fluoroscopic, US, CT, or even MR guidance depending on the location to be accessed, type of pathology, patient characteristics, and physician preferences. 4
11. Fayad LM, Carrino JA, Fishman EK. Musculoskeletal infection: role of CT in the emergency department. Radiographics. 2007;27(6):1723-1736. Review/Other-Dx 1,196 patients: 1,122 had suspected soft-tissue infection, and 74 had suspected bone infection To examine the role of CT in the evaluation of musculoskeletal infections in the emergency department of a large inner-city hospital. CT plays an important role in the assessment of potential musculoskeletal infections in the emergency department. CT provides an analysis of compartmental anatomy, thereby helping to distinguish among the various types of musculoskeletal infection and to guide treatment options. 4
12. Soldatos T, Durand DJ, Subhawong TK, Carrino JA, Chhabra A. Magnetic resonance imaging of musculoskeletal infections: systematic diagnostic assessment and key points. Acad Radiol 2012;19:1434-43. Review/Other-Dx N/A To describe the MRI features along the full spectrum of musculoskeletal infections and provide several illustrative case examples. No results stated in abstract. 4
13. Alaia EF, Chhabra A, Simpfendorfer CS, et al. MRI nomenclature for musculoskeletal infection. [Review]. Skeletal Radiol. 50(12):2319-2347, 2021 Dec. Review/Other-Dx N/A To critically assess the literature and propose standardized terminology for imaging findings of infection on MRI, in order to improve both communication with clinical colleagues and patient care. No results stated in abstract. 4
14. Gaspari R, Dayno M, Briones J, Blehar D. Comparison of computerized tomography and ultrasound for diagnosing soft tissue abscesses. Crit Ultrasound J 2012;4:5. Observational-Dx 65 patients To compare the diagnostic accuracy of CT and US in patients with skin and soft tissue infections. Over an 18 month period 612 patients received a soft tissue bedside ultrasound with 65 of those patients receiving a CT for the same complaint. 30 of these 65 patients had an abscess located in the head and neck (37%), buttock (17%), lower extremity (17%), upper extremity (13%), torso (13%), or hand (3%). US demonstrated a sensitivity and specificity for the diagnosis of abscess of 96.7% (87.0% to 99.4%) and 85.7% (77.4% to 88.0%) respectively. The overall sensitivity and specificity of CT for the diagnosis of an abscess was 76.7% (65.5% to 82.8%) and 91.4% (81.8% to 96.7%) respectively Overall image detail ratings were superior for US compared to CT (3.5 vs 2.3, p = 0.0001). 2
15. Glaudemans AWJM, Jutte PC, Cataldo MA, et al. Consensus document for the diagnosis of peripheral bone infection in adults: a joint paper by the EANM, EBJIS, and ESR (with ESCMID endorsement). European Journal of Nuclear Medicine & Molecular Imaging. 46(4):957-970, 2019 Apr. Review/Other-Dx N/A To provide an evidence-based, multidisciplinary consensus document on the diagnostic management of adult patients with peripheral bone infection. No results stated in abstract. 4
16. Math KR, Berkowitz JL, Paget SA, Endo Y. Imaging of Musculoskeletal Infection. [Review]. Rheum Dis Clin North Am. 42(4):769-784, 2016 11. Review/Other-Dx N/A To the discuss the role of diagnostic imaging in confirming the diagnosis of musculoskeletal (MSK) infection and determining the severity and extent of disease. No results stated in abstract. 4
17. Wang GL, Zhao K, Liu ZF, Dong MJ, Yang SY. A meta-analysis of fluorodeoxyglucose-positron emission tomography versus scintigraphy in the evaluation of suspected osteomyelitis. Nucl Med Commun. 32(12):1134-42, 2011 Dec. Meta-analysis 23 studies representing 851 examinations To perform a meta-analysis to obtain a reliable estimate of the diagnostic performance of FDG-PET, three-phase bone scintigraphy, leukocyte scintigraphy, and monoclonal antigranulocyte antibody scintigraphy in the assessment of suspected osteomyelitis and to perform pairwise comparisons of the diagnostic accuracy between these different imaging modalities. The FDG-PET had a pooled sensitivity of 0.923, specificity of 0.920, and AUC of 0.9666, whereas for bone scintigraphy, the corresponding values were 0.827, 0.446, and 0.6514, respectively, for leukocyte scintigraphy, the corresponding values were 0.742, 0.881, and 0.9139, respectively, and for monoclonal antigranulocyte antibody, the corresponding values were 0.883, 0.705, and 0.8897, respectively. The meta-analysis did not find statistically significant differences in the sensitivity, specificity, AUC, and Q* index between FDG-PET and leukocyte scintigraphy. M
18. Love C, Palestro CJ. Nuclear medicine imaging of bone infections. [Review]. Clin Radiol. 71(7):632-46, 2016 Jul. Review/Other-Dx N/A To discuss the role of nuclear medicine in bone infection. No results stated in abstract. 4
19. Horger M, Eschmann SM, Pfannenberg C, et al. Added value of SPECT/CT in patients suspected of having bone infection: preliminary results. Arch Orthop Trauma Surg. 2007;127(3):211-221. Observational-Dx 31 patients To evaluate the contribution of SPECT/CT as an adjunct to combined three-phase bone scintigraphy (planar and SPECT) for diagnosing and localizing bone infection. Subsequently, the diagnostic performance of SPECT/CT was compared to visual fusion of SPECT with data of additional CT, X-ray, or MRI studies (SPECT + CT/X-ray/MRI). Three-phase bone scan (incl. SPECT) correctly classified 7 lesions as positive and 11 lesions as negative for osteomyelitis. 6 scans were interpreted false positive, 2 false negative, and 5 as equivocal. Rating the latter as positive for osteomyelitis, sensitivity of bone scan was (78%), specificity (50%). SPECT/CT was true positive in 7 patients, and true negative in 19. There were 2 false positive and 2 false negative findings, 1 scan was equivocal (sensitivity 78%, specificity 86%). Definition of anatomical localization of inflammatory foci was much easier by SPECT/CT due to better depiction of underlying anatomical details. SPECT + CT/X-ray/MRI yielded the highest sensitivity (100% compared to 78% of SPECT/CT), if equivocal findings (5/31 compared to 1/31 for SPECT/CT) are rated as true positive for osteomyelitis. Among radiological techniques, MRI (2 x false positive) and CT (2 x false negative) proved equal and expectedly superior to X-ray in delivering the correct diagnosis. 3
20. Palestro CJ.. FDG-PET in musculoskeletal infections. [Review]. Semin Nucl Med. 43(5):367-76, 2013 Sep. Review/Other-Dx N/A To review role of FDG-PET in musculoskeletal infections. FDG-PET (PET/CT) is assuming an increasingly important role in the diagnostic workup of musculoskeletal infection. FDG offers advantages over conventional radionuclide techniques. 4
21. Govaert GA, IJpma FF, McNally M, McNally E, Reininga IH, Glaudemans AW. Accuracy of diagnostic imaging modalities for peripheral post-traumatic osteomyelitis - a systematic review of the recent literature. [Review]. European Journal of Nuclear Medicine & Molecular Imaging. 44(8):1393-1407, 2017 Aug. Review/Other-Dx 10 articles To present a systematic review of the recent literature on diagnostic imaging of PTO. Four of studies had a comparative design which made it possible to report the results of, in total, 17 patient series. WBC (or AGA) scintigraphy and FDG-PET exhibit good accuracy for diagnosing PTO (sensitivity ranged from 50-100%, specificity ranged from 40-97% versus 83-100% and 51%-100%, respectively). The accuracy of both modalities improved when a hybrid imaging technique (SPECT/CT & FDG-PET/CT) was performed. For FDG-PET/CT, sensitivity ranged between 86 and 94% and specificity between 76 and 100%. For WBC scintigraphy + SPECT/CT, this is 100% and 89-97%, respectively. 4
22. Wenter V, Muller JP, Albert NL, et al. The diagnostic value of [(18)F]FDG PET for the detection of chronic osteomyelitis and implant-associated infection. Eur J Nucl Med Mol Imaging. 43(4):749-61, 2016 Apr. Observational-Dx 215 patients To evaluate the contributions of [(18)F]FDG PET and [(18)F]FDG PET/CT to the diagnosis of osteomyelitis and implant-associated infections, enabling timely and appropriate decision-making for further therapy options. PET and PET/CT scans revealed 87 true-positive, 76 true-negative, 38 false-positive, and 14 false-negative results, indicating a sensitivity of 86 %, a specificity of 67 %, a positive predictive value (PPV) of 70 %, a negative predictive value (NPV) of 84 % and an accuracy of 76 %. The sensitivity of PET/CT was 88 %, but specificity, PPV, NPV and accuracy (76 %, 76 %, 89 % and 82 %, respectively) were higher than those of stand-alone PET. 2
23. Collins MS, Schaar MM, Wenger DE, Mandrekar JN. T1-weighted MRI characteristics of pedal osteomyelitis. AJR Am J Roentgenol. 185(2):386-93, 2005 Aug. Observational-Dx 80 feet in 80 patients To directly evaluate the reliability of primary T1 findings in surgically proven cases of pedal osteomyelitis. Decreased T1 marrow signal in a geographic medullary distribution with a confluent pattern and concordance with fat-suppressed T2- and T1-weighted postcontrast signal abnormality was present in 100% of the surgically proven cases of pedal osteomyelitis. None of the patients with decreased T1 marrow signal in a subcortical distribution or in a hazy, reticulated pattern had surgically proven osteomyelitis regardless of the fat-suppressed T2-weighted or postcontrast T1-weighted findings. 3
24. Connolly SA, Connolly LP, Drubach LA, Zurakowski D, Jaramillo D. MRI for detection of abscess in acute osteomyelitis of the pelvis in children. AJR Am J Roentgenol. 2007; 189(4):867-872. Observational-Dx 38 children; 2 blinded reviewers Retrospectively review the imaging studies and medical records of children who were diagnosed with pelvic osteomyelitis using MRI during a 5-year period to determine how often fluid collections indicative of abscess on MRI occur in pelvic acute hematogenous osteomyelitis and whether clinical parameters can predict the occurrence of such abscesses. Osteomyelitis involved metaphyseal equivalent sites in every case (n=38), with single bone involvement in 24 (63%) and contiguous bone involvement in the remaining 14 (37%). Fluid collections indicative of an abscess were seen in 21 cases (55%), and abscess drainage was performed in 10 (26%). Univariate analysis of demographic and clinical variables between patients with and without an abscess indicated no significant differences for any variable except ESR (74 +/- 19 vs 56 +/- 24 mm/h; P<0.05, Student’s t test). Childhood pelvic acute hematogenous osteomyelitis is relatively uncommon and produces variable signs and symptoms that are often attributed to another process. Study results show the ability of MRI to provide additional information that affected patient management in cases of pelvic abscess. Authors recommend the use of MRI as the imaging technique of choice for any child suspected of having pelvic acute hematogenous osteomyelitis. 3
25. Hauptfleisch J, Meagher TM, Hughes RJ, Singh JP, Graham A, Lopez de Heredia L. Interobserver agreement of magnetic resonance imaging signs of osteomyelitis in pelvic pressure ulcers in patients with spinal cord injury. Arch Phys Med Rehabil. 2013;94(6):1107-1111. Observational-Dx 37 patients To examine the interobserver reliability of MRI signs of osteomyelitis in complex chronic pressure ulcers in patients with spinal cord injury. 37 patients underwent 41 MRI scans. Concordance for marrow edema was 71% on both short tau inversion recovery and T1-weighted sequences, and for cortical erosion was 85%. 4
26. Johnson PW, Collins MS, Wenger DE. Diagnostic utility of T1-weighted MRI characteristics in evaluation of osteomyelitis of the foot. AJR Am J Roentgenol. 192(1):96-100, 2009 Jan. Observational-Dx 74 examinations of 73 patients To evaluate the diagnostic utility of specific characteristics on T1-weighted MRIs in the diagnosis of pedal osteomyelitis. Images from 74 examinations were evaluated. In 20 cases, osteomyelitis was considered present, and in 54 it was presumed absent. In 19/20 cases (95%) in which osteomyelitis was considered present, marrow T1 signal intensity was decreased, in a medullary distribution, and in a confluent pattern in all cases. In 30/54 cases (56%) in which osteomyelitis was presumed absent, T1 signal intensity was decreased, but only 5 cases (9%) had a medullary distribution and confluent pattern. 23 cases (43%) had a hazy reticulated pattern, and 2 cases (4%) had only subcortical distribution. None of the cases with a subcortical distribution or hazy reticulated pattern of abnormal signal intensity had positive results for osteomyelitis. Confluent decreased T1 marrow signal intensity in a medullary distribution was 95% sensitive in the prediction of osteomyelitis with a specificity of 91%, negative predictive value of 98%, and PPV of 79%. 3
27. Kan JH, Young RS, Yu C, Hernanz-Schulman M. Clinical impact of gadolinium in the MRI diagnosis of musculoskeletal infection in children. Pediatr Radiol. 40(7):1197-205, 2010 Jul. Observational-Dx 90 gadolinium-enhanced MRIs To compare diagnostic utility of non-contrast with contrast MRI in the evaluation of pediatric musculoskeletal infections. Pre- and post-contrast diagnosis of osteomyelitis sensitivity was 89% and 91% (P=1.00) and specificity was 96% and 96% (P=1.00), respectively; septic arthritis sensitivity was 50% and 67% (P=1.00) and specificity was 98% and 98% (P=1.00), respectively; cellulitis/myositis sensitivity was 100% and 100% (P=1.00) and specificity was 84% and 88% (P=0.59), respectively; abscess for the total group was 22 (24.4%) and 42 (46.6%), respectively (P<0.0001). Abscesses identified only on contrast sequences led to intervention in eight additional children. No child with a final diagnosis of infection had a normal pre-contrast study. Intravenous gadolinium should not be routinely administered in the imaging work-up of nonspinal musculoskeletal infections, particularly when pre-contrast images are normal. However, gadolinium contrast significantly increases the detection of abscesses, particularly small ones that might not require surgical intervention. 3
28. Balanika AP, Papakonstantinou O, Kontopoulou CJ, et al. Gray-scale and color Doppler ultrasonographic evaluation of reactivated post-traumatic/postoperative chronic osteomyelitis. Skeletal Radiol. 2009;38(4):363-369. Observational-Dx 40 patients To carry out a systematic assessment of gray-scale and color Doppler US findings of reactivated post-traumatic/postoperative chronic osteomyelitis in adults. Statistically significant differences between patients with and without reactivated chronic osteomyelitis were found for fistulous tracts (P<0.0001), juxtacortical fluid collections (P<0.001) periosteal thickening (P<0.01), distension of pseudocapsule (P<0.05), and periosteal vascularity (P<0.0001). Low-resistance arterial flow of periosteal vessels presented the highest sensitivity (92%), specificity, and PPV (100%), yielding only 2 false negative results in 2 obese patients. Among gray-scale findings, the presence of a fistulous tract yielded the highest specificity and PPV (100%), whereas periosteal thickening was the most sensitive (92%), though not specific, finding (specificity 50%). 3
29. Ertugrul MB, Baktiroglu S, Salman S, et al. The diagnosis of osteomyelitis of the foot in diabetes: microbiological examination vs. magnetic resonance imaging and labelled leucocyte scanning. Diabet Med. 2006; 23(6):649-653. Observational-Dx 31 total patients: 28 MRI, 26 Tc-99m WBC+Tc-MDP To compare the diagnostic values of Tc-labeled leucocyte, MRI and microbiological examination of bone tissue specimens with histopathology, the definitive diagnostic procedure. Microbiology had a sensitivity of 92% and specificity of 60%. Labeled leucocyte scanning had a sensitivity of 91%, specificity of 67%. MRI a sensitivity of 78%, specificity of 60%. Microbiological: 92% sensitivity, 60% specificity, PPV 92%, NPV 60%. MRI: 78% sensitivity, 60% sensitivity, PPV 90%, NPV 37.5%. Tc-WBC: 91% sensitivity, 67% sensitivity, PPV 95%, NPV 50%. Microbiological examination may be as useful as and less costly than other diagnostic procedures and is the only method which can guide the choice of antibiotic therapy. 3
30. Hartmann A, Eid K, Dora C, Trentz O, von Schulthess GK, Stumpe KD. Diagnostic value of 18F-FDG PET/CT in trauma patients with suspected chronic osteomyelitis. Eur J Nucl Med Mol Imaging. 2007;34(5):704-714. Observational-Dx 33 patients To retrospectively evaluate the diagnostic value of FDG-PET/CT in trauma patients with suspected chronic osteomyelitis. Of 33 PET/CT scans, 17 were true positive, 13 true negative, 2 false positive and 1 false negative. 18 patients had chronic osteomyelitis and 15 had no osseous infection according to the reference standard. Sensitivity, specificity and accuracy for FDG-PET/CT was 94%, 87% and 91% for the whole group, 88%, 100% and 90% for the axial skeleton and 100%, 85% and 91% for the appendicular skeleton, respectively. 3
31. Signore A, Sconfienza LM, Borens O, et al. Consensus document for the diagnosis of prosthetic joint infections: a joint paper by the EANM, EBJIS, and ESR (with ESCMID endorsement). European Journal of Nuclear Medicine & Molecular Imaging. 46(4):971-988, 2019 Apr. Review/Other-Dx N/A To address and provide evidence-based answers on uniform statements for the diagnosis of prosthetic joint infection. No results stated in abstract. 4
32. Zalavras CG, Rigopoulos N, Lee J, Learch T, Patzakis MJ. Magnetic resonance imaging findings in hematogenous osteomyelitis of the hip in adults. Clin Orthop Relat Res. 2009;467(7):1688-1692. Review/Other-Dx 11 adult patients (12 hips) To determine the extent of bone involvement and the presence of adjacent soft tissue abscesses in adults with hip osteomyelitis. MRI revealed osteomyelitis distal to the femoral head in 7/12 hips with extension into the medullary canal in 3 of these 7. Femoral head erosions were present in 10 hips, acetabulum osteomyelitis in 11, and acetabular erosions in 6 hips. Infection extended into adjacent soft tissues in 8/12 hips. MRI demonstrated that the infection may extend distal to the femoral head or into the adjacent soft tissues. MRI may be useful for preoperative planning so that all regions affected by the infection can be treated. 4
33. Bohndorf K. Infection of the appendicular skeleton. Eur Radiol. 2004;14 Suppl 3:E53-63. Review/Other-Dx N/A To review imaging of acute, subacute and chronic osteomyelitis. The diagnosis of acute osteomyelitis is often challenging but can best be made by correlating radiography, bone scintigraphy and MRI with clinical information. Radiography should routinely be supplemented by sonography in the newborns and infants, if applicable. Brodie's abscess, which is clinically a subacute form of osteomyelitis, is best diagnosed by the combination of radiography and MRI. Chronic osteomyelitis is divided into primary hematogenous forms and exogenous, mostly post-traumatic, osteomyelitis. In the majority of patients, post-traumatic osteomyelitis is a clinical diagnosis; however, in a number of patients only the correlation of clinical findings, blood tests and imaging reveals the correct diagnosis. Often, MRI and scintigraphic methods, such as scanning with labeled leucocytes, together establish the diagnosis. 4
34. Trevail C, Ravindranath-Reddy P, Sulkin T, Bartlett G. An evaluation of the role of nuclear medicine imaging in the diagnosis of periprosthetic infections of the hip. Clin Radiol. 71(3):211-9, 2016 Mar. Observational-Dx 235 patients To validate the role of nuclear medicine (NM) imaging in hip periprosthetic joint infection (PJI) of hip arthroplasties. There were 14 exclusions. Of the 221 remaining patients, there were 16 true positives, one false positive, 200 true negatives, and four false negatives. The algorithm used at this centre demonstrated an accuracy of 97.7% with high specificity of 99.5% and sensitivity of 80%. 3
35. Palestro CJ, Love C. Role of Nuclear Medicine for Diagnosing Infection of Recently Implanted Lower Extremity Arthroplasties. [Review]. Semin Nucl Med. 47(6):630-638, 2017 11. Review/Other-Dx N/A To discuss the role of nuclear medicine for evaluating painful joint replacements. No results stated in abstract. 4
36. Verberne SJ, Raijmakers PG, Temmerman OP. The Accuracy of Imaging Techniques in the Assessment of Periprosthetic Hip Infection: A Systematic Review and Meta-Analysis. [Review]. J Bone Joint Surg Am. 98(19):1638-1645, 2016 Oct 05. Meta-analysis 31 studies representing 1,753 hip prostheses. To determine the accuracy of current imaging modalities in diagnosing periprosthetic hip infection. The pooled sensitivity and specificity were 88% (95% confidence interval [CI], 81% to 94%) and 92% (95% CI, 88% to 96%), respectively, for leukocyte scintigraphy; 86% (95% CI, 80% to 90%) and 93% (95% CI, 90% to 95%) for fluorodeoxyglucose positron emission tomography (FDG PET); 69% (95% CI, 58% to 79%) and 96% (95% CI, 93% to 98%) for combined leukocyte and bone marrow scintigraphy; 84% (95% CI, 70% to 93%) and 75% (95% CI, 66% to 82%) for antigranulocyte scintigraphy; and 80% (95% CI, 72% to 86%) and 69% (95% CI, 64% to 73%) for bone scintigraphy. Inadequate
37. Hill DS, Kinsella D, Toms AD. Three-phase Technetium-99m bone scanning in patients with pain in the knee region after cemented total knee arthroplasty. Eur. j. orthop. surg. traumatol.. 29(5):1105-1113, 2019 Jul. Observational-Dx 118 patients To question the usefulness of a three-phase bone scan in the evaluation of pain in the knee region after TKR. Thirty-three per cent (39/118) of TPBSs were reported as being entirely normal, 59% (69/118) as possibly abnormal, and 8% (10/118) as definitely abnormal. During the 24-month study period, 131 revision TKR procedures were performed at our institution; 9% (12/131) were investigated with TPBS and 91% (119/131) were not. No patient with an entirely normal pre-operative TPBS underwent revision TKR surgery. Eighty-five per cent (67/79) with an abnormal TPBS were managed conservatively. In our series, a TPBS had a positive predictive value of 2.53%, a negative predictive value of 100%, with an overall accuracy of 34.75% with 100% sensitivity (97.5% one-sided confidence interval 0-24.71%), and 33.62% specificity (95% confidence interval 53.29-72.37%), in the diagnosis of infection, or loosening with concurrent infection in determining the indication for revision surgery. 3
38. Isern-Kebschull J, Tomas X, Garcia-Diez AI, Morata L, Rios J, Soriano A. Accuracy of Computed Tomography-Guided Joint Aspiration and Computed Tomography Findings for Prediction of Infected Hip Prosthesis. J Arthroplasty. 34(8):1776-1782, 2019 Aug. Observational-Dx 96 patients To assess the accuracy of computed tomography (CT)-guided joint aspiration combined with CT findings for prediction of septic hip prosthesis before revision surgery. Septic hip prosthesis was shown on revision surgery in 35 patients (36.4%), with Staphylococcus epidermidis isolated in 54.3% of cases. Culture of the aspirated fluid yielded the same microorganism in 24 patients (68.6%). The accuracy of preoperative CT-guided joint aspiration was 86.5%. High volume (>1 mL) of aspirated fluid was recorded in 32 patients (33.3%). 2
39. Randelli F, Brioschi M, Randelli P, Ambrogi F, Sdao S, Aliprandi A. Fluoroscopy- vs ultrasound-guided aspiration techniques in the management of periprosthetic joint infection: which is the best?. Radiol Med (Torino). 123(1):28-35, 2018 Jan. Observational-Dx 49 patients To determine whether (1) the benefits in terms of sensitivity and specificity and (2) the costs were comparable between fluoroscopy- and ultrasound-guided joint aspirations in a suspicious of hip PJI. (1) Ultrasound-guided aspiration revealed valid sensitivity (89% vs 60%) and specificity (94% vs 81%) in comparison with fluoroscopic-guided aspiration. (2) The cost analysis was also in favor of ultrasound-guided aspiration (125.30€) than fluoroscopic-guided aspiration (343.58€). 3
40. Bhoil A, Caw H, Vinjamuri S. Role of 18F-flurodeoxyglucose in orthopaedic implant-related infection: review of literature and experience. [Review]. Nucl Med Commun. 40(9):875-887, 2019 Sep. Review/Other-Dx N/A To present a review of recently used tracers, and share our experience with using 18F-FDG PET/CT studies in a few diverse clinical settings related to post-metal implant osteomyelitis. No results stated in abstract. 4
41. Karchevsky M, Schweitzer ME, Morrison WB, Parellada JA. MRI findings of septic arthritis and associated osteomyelitis in adults. AJR Am J Roentgenol. 2004;182(1):119-122. Observational-Dx 50 consecutive cases of septic arthritis in 38 patients To describe the soft-tissue, synovial, and osseous MRI findings of septic arthritis. The frequency of MRI findings in septic joints was as follows: synovial enhancement (98%), perisynovial edema (84%), joint effusions (70%), fluid outpouching (53%), fluid enhancement (30%), and synovial thickening (22%). The marrow showed bare area changes (86%), abnormal T2 signal (84%), abnormal gadolinium enhancement (81%), and abnormal T1 signal (66%). Associated osteomyelitis more often showed T1 signal abnormalities and was diffuse. 3
42. Backer HC, Steurer-Dober I, Beck M, et al. Magnetic resonance imaging (MRI) versus single photon emission computed tomography (SPECT/CT) in painful total hip arthroplasty: a comparative multi-institutional analysis. Br J Radiol. 93(1105):20190738, 2020 Jan. Observational-Dx 35 consecutive patients with 37-painful hip arthroplasties To investigate the value of MRI in comparison to single photon emission computed tomography (SPECT)/CT in patients with painful hip arthroplasties. Loosening was observed in 13/37 arthroplasties (6 shaft only, 6 cup only, 1 combined). Sensitivity, specificity, positive predictive value and negative predictive value for loosening of MRI were 86%/88%/60%/100% and of SPECT/CT 93%/97%/90%/100%, respectively. MRI and SPECT/CT diagnosed infection correctly in two of three patients and fractures in two patients, which were missed by X-ray. MRI detected soft tissue abnormalities in 21 patients (6 bursitis, 14 tendon lesions, 1 pseudotumor), of which only 1 tendon abnormality was accurately detected with SPECT/CT. All 5 arthroplasties with polyethylene wear were correctly diagnosed clinically and with both imaging modalities. MRI and SPECT/CT were judged as not helpful in 0/0%, as helpful in 16%/49% and essential in 84%/51%. 1
43. Yu JS, Habib P. MR imaging of urgent inflammatory and infectious conditions affecting the soft tissues of the musculoskeletal system. Emerg Radiol. 2009;16(4):267-276. Review/Other-Dx N/A To review soft tissue infections and inflammatory conditions of the musculoskeletal system. The characteristic imaging findings of cellulitis, abscess formation, necrotizing fasciitis, pyomyositis, diabetic ischemic infarction, acute and exertional compartment syndromes, and rhabdomyolysis are emphasized as well as imaging factors that can help to differentiate these disorders. MRI is currently the best imaging modality to evaluate these conditions. 4
44. Brammen L, Palestro CJ, Holinka J, Windhager R, Sinzinger H. A retrospective analysis of the accuracy of radioactively labeled autologous leukocytes in patients with infected prosthetic joints. Nucl Med Rev Cent East Eur. 20(2):81-87, 2017. Observational-Dx 48 patients To determine the accuracy of LS combined with bone marrow scintigraphy (BMS), as well as inflammation markers CRP and WBC, in detecting infection in patients with prosthetic joints. The most common joint investigated was knee (25), followed by hip (9), shoulder (2), and elbow (1). Other parts of the body investigated included the femur (6), tibia (2), leg (2), and foot (1). The pathogens most frequently isolated included Staphylococcus epidermidis and Candida albicans. The sensitivity of LS was 60%, specificity 97%, PPV 86% and NPV 90%. Overall accuracy was calculated to be 90%. 3
45. van der Bruggen W, Bleeker-Rovers CP, Boerman OC, Gotthardt M, Oyen WJ. PET and SPECT in osteomyelitis and prosthetic bone and joint infections: a systematic review. [Review] [59 refs]. Semin Nucl Med. 40(1):3-15, 2010 Jan. Review/Other-Dx 44 original articles; 1,634 patients (580 patients SPECT, 1,054 patients FDG-PET) To review the literature on diagnostic accuracy and clinical value of SPECT and PET for imaging of bone and joint infections. In 44 original articles (15 for SPECT and 29 for FDG-PET) on osteomyelitis and prosthetic bone and joint infection, 1,634 patients were included (580 patients SPECT, 1,054 patients FDG-PET). Level of evidence (Oxford criteria) was 2-3b. For SPECT, the highest diagnostic accuracy of 95% for diagnosis of bone and joint infections is achieved with combined (111)In-WBC and (99m)Tc-sulfur colloid. Acceptable diagnostic accuracy was also obtained with (99m)Tc-WBC or (111)In-WBC combined with (99m)Tc-methylene diphosphonate. FDG-PET is useful for diagnosis of osteomyelitis with a sensitivity and specificity generally over 95%. In patients with orthopedic implant infections, sensitivity varies widely from 28% to 91% and specificity from 9% to 97%. This variation in FDG-PET performance in orthopedic implant infections depends largely on the (use of different) criteria to diagnose infection. Determination of the best criteria is still a matter of debate. 4
46. Carneiro BC, Cruz IAN, Chemin RN, et al. Multimodality Imaging of Foreign Bodies: New Insights into Old Challenges. [Review]. Radiographics. 40(7):1965-1986, 2020 Nov-Dec.Radiographics. 40(7):1965-1986, 2020 Nov-Dec. Review/Other-Dx N/A To discuss and illustrate how a multimodal imaging approach may provide tools to create an effective thinking methodology. No results stated in abstract. 4
47. Jarraya M, Hayashi D, de Villiers RV, et al. Multimodality imaging of foreign bodies of the musculoskeletal system. [Review]. AJR Am J Roentgenol. 203(1):W92-102, 2014 Jul. Review/Other-Dx N/A To clarify the most relevant points in managing suspected foreign bodies of the musculoskeletal system on the basis of a literature review and published reports with cases to illustrate each type on different imaging modalities. Foreign bodies of the musculoskeletal system are a common problem in emergency departments, with more than a third missed in the initial clinical evaluation. These retained objects may result in various complications and also offer fertile ground for litigation. 4
48. Tantray MD, Rather A, Manaan Q, Andleeb I, Mohammad M, Gull Y. Role of ultrasound in detection of radiolucent foreign bodies in extremities. Strategies Trauma Limb Reconstr 2018;13:81-85. Observational-Dx 120 patients To determine effectiveness of sonography for detection of radiolucent foreign bodies and to summarize the experiences using sonography in the management of patients with a suspected retained foreign body. Out of 120 patients who underwent surgical exploration, USG was positive in 114 cases, and foreign body was retrieved in 108 cases, and among the six cases where USG was negative, foreign body was retrieved from one case. In one case with strong clinical suspicion of foreign body USG was falsely negative. Majority of foreign bodies were removed from foot (69 cases) and hands (26 cases), and rest of foreign bodies were removed from ankle (4 cases), wrist (3 cases), thigh (2 cases), leg (1 case), knee (2 cases), forearm (2 cases). Accuracy, sensitivity, and positive predictive value were determined as 94.16, 99.08, and 94.13%, respectively. 2
49. Chaudhry AA, Baker KS, Gould ES, Gupta R. Necrotizing fasciitis and its mimics: what radiologists need to know. [Review]. AJR Am J Roentgenol. 204(1):128-39, 2015 Jan. Review/Other-Dx N/A To review the imaging features of necrotizing fasciitis and its potential mimics. No results stated in abstract. 4
50. Yoon MA, Chung HW, Yeo Y, et al. Distinguishing necrotizing from non-necrotizing fasciitis: a new predictive scoring integrating MRI in the LRINEC score. Eur Radiol. 29(7):3414-3423, 2019 Jul. Observational-Dx 96 subjects To develop and validate a scoring system integrating MRI and laboratory findings to differentiate necrotizing fasciitis (NF) from non-necrotizing fasciitis (non-NF). The final scoring system consisted of three variables: thickening of the deep fascia = 3 mm, multi-compartmental involvement, and LRINEC score. The new predictive model showed improved performance (area under the receiver operating characteristic curve [AUC], 0.862; positive and negative predictive values, 82% and 79%, respectively), compared with the LRINEC score alone (0.814, 77% and 67%, respectively). The model also showed good discrimination with the external validation dataset (AUC, 0.933). 2
51. Carbonetti F, Cremona A, Carusi V, et al. The role of contrast enhanced computed tomography in the diagnosis of necrotizing fasciitis and comparison with the laboratory risk indicator for necrotizing fasciitis (LRINEC). Radiol Med (Torino). 121(2):106-21, 2016 Feb. Observational-Dx 36 patients To evaluate the diagnostic efficacy of contrast enhanced computed tomography (CECT) in emergency departments for diagnosis of necrotizing fasciitis (NF) and for differential diagnosis of other musculoskeletal infections; to correlate radiological findings with the laboratory risk indicator for necrotizing fasciitis (LRINEC). wo parameters were found to be strongly associated with the diagnosis of NF: involvement of the fascia (Spearman's ? of 0.888, p < 0.001) and lack of fascial enhancement (Spearman's ? of 0.672, p < 0.001). LRINEC score did not show strong association with the presence of fasciitis NF (Spearman's ? of 0.490, p = 0.0024). 3
52. Tso DK, Singh AK. Necrotizing fasciitis of the lower extremity: imaging pearls and pitfalls. Br J Radiol. 91(1088):20180093, 2018 Jul. Review/Other-Dx N/A To review the imaging findings of necrotizing fasciitis as seen on radiograph, ultrasound, CT, and MRI, and to recognize the early findings in this potentially fatal disease. No results stated in abstract. 4
53. Wysoki MG, Santora TA, Shah RM, Friedman AC. Necrotizing fasciitis: CT characteristics. Radiology 1997;203:859-63. Review/Other-Dx 20 patients To establish computed tomographic (CT) criteria for the diagnosis of necrotizing fasciitis. Four patients (20%) died. Asymmetric fascial thickening and fat stranding were seen in 16 patients (80%). Gas tracking along fascial planes was present in 11 patients (55%), and abscesses were found in seven patients (35%). Infection sites were scrotum (n = 6), a lower extremity (n = 4), perineum (n = 4), neck (n = 2), back (n = 2), arm (n = 1), and abdomen (n = 1). Underlying illness (n = 17) was diabetes in 10 patients (50%), alcoholism in three (15%), chronic renal failure in two (10%), and drug abuse in two (10%). 4
54. Fernando SM, Tran A, Cheng W, et al. Necrotizing Soft Tissue Infection: Diagnostic Accuracy of Physical Examination, Imaging, and LRINEC Score: A Systematic Review and Meta-Analysis. Ann Surg. 269(1):58-65, 2019 01. Meta-analysis 23 studies (n = 5982) To summarize accuracy of physical examination, imaging, and Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score in diagnosis of necrotizing soft tissue infection (NSTI) in adults with a soft tissue infection clinically concerning for NSTI. Of physical examination signs, pooled sensitivity and specificity for fever was 46.0% and 77.0% respectively, for hemorrhagic bullae 25.2% and 95.8%, and for hypotension 21.0% and 97.7%. Computed tomography (CT) had sensitivity of 88.5% and specificity of 93.3%, while plain radiography had sensitivity of 48.9% and specificity of 94.0%. Finally, LRINEC = 6 had sensitivity of 68.2% and specificity of 84.8%, while LRINEC = 8 had sensitivity of 40.8% and specificity of 94.9%. Good
55. Stevens DL, Bryant AE. Necrotizing Soft-Tissue Infections. N Engl J Med 2017;377:2253-65. Review/Other-Dx N/A To discuss the diagnosis and management of necrotizing fasciitis. No results stated in abstract. 4
56. Kim KT, Kim YJ, Won Lee J, et al. Can necrotizing infectious fasciitis be differentiated from nonnecrotizing infectious fasciitis with MR imaging? Radiology 2011;259:816-24. Observational-Dx 165 patients To retrospectively evaluate whether magnetic resonance (MR) imaging findings can be used to differentiate necrotizing infectious fasciitis (NIF) from nonnecrotizing infectious fasciitis (non-NIF). The patients with NIF had a significantly greater frequency of (a) thick (=3 mm) abnormal signal intensity on fat-suppressed T2-weighted images, (b) low signal intensity in the deep fascia on fat-suppressed T2-weighted images, (c) a focal or diffuse nonenhancing portion in the area of abnormal signal intensity in the deep fascia, (d) extensive involvement of the deep fascia, and (e) involvement of three or more compartments in one extremity (P < .05). 3
57. Malghem J, Lecouvet FE, Omoumi P, Maldague BE, Vande Berg BC. Necrotizing fasciitis: contribution and limitations of diagnostic imaging. Joint Bone Spine 2013;80:146-54. Review/Other-Dx N/A To discuss the role of diagnostic imaging in the diagnosis of necrotizing fasciitis No results stated in abstract. 4
58. Schmid MR, Kossmann T, Duewell S. Differentiation of necrotizing fasciitis and cellulitis using MR imaging. AJR Am J Roentgenol 1998;170:615-20. Observational-Dx 15 patients To evaluate the diagnostic value of MR imaging in differentiating necrotizing fasciitis from cellulitis. Cellulitis was diagnosed when subcutaneous thickening with fluid collections was revealed on T2-weighted images and when subcutaneous tissue or superficial fascia or both showed contrast enhancement. For the diagnosis of necrotizing fasciitis, imaging revealed additional involvement of deep fasciae with fluid collections, thickening, and enhancement after contrast administration. According to these criteria, we found 11 cases of necrotizing fasciitis and six of cellulitis. MR imaging identified all 11 cases of necrotizing fasciitis correctly when compared with the surgical findings. One false-positive case of cellulitis was overstaged and was thought to be necrotizing fasciitis. Contrast-enhanced T1-weighted sequences delineated abscesses and areas of necrosis more clearly than T2-weighted sequences did, but showed no additional lesions. 3
59. Clark ML, Fisher KL. Sonographic Detection of Necrotizing Fasciitis. Journal of Diagnostic Medical Sonography 2017;33:311-16. Review/Other-Dx 1 case To review a case that demonstrates the use of sonography to assist in the detection and characterization of necrotizing fasciitis. No results stated in abstract. 4
60. Lin CN, Hsiao CT, Chang CP, et al. The Relationship Between Fluid Accumulation in Ultrasonography and the Diagnosis and Prognosis of Patients with Necrotizing Fasciitis. Ultrasound Med Biol. 45(7):1545-1550, 2019 07. Observational-Dx 95 patients To evaluate the relationship between the ultrasonographic finding of fluid accumulation along the deep fascia and the diagnosis and prognosis of NF. The ultrasonographic finding of fluid accumulation with a cutoff point of more than 2 mm of depth had the best accuracy (72.7%) for diagnosing necrotizing fasciitis. In regard to the prognosis of necrotizing fasciitis, when fluid accumulation was present along the deep fascia, patients with necrotizing fasciitis had a longer length of hospital stay and were at risk of amputation or mortality. 3
61. Castleberg E, Jenson N, Dinh VA. Diagnosis of necrotizing faciitis with bedside ultrasound: the STAFF Exam. West J Emerg Med 2014;15:111-3. Review/Other-Dx 1 case report To present a case of necrotizing fasciitis that was rapidly diagnosed using bedside ultrasound evaluating for subcutaneous thickening, air, and fascial fluid (STAFF). No results stated in abstract. 4
62. Wronski M, Slodkowski M, Cebulski W, Karkocha D, Krasnodebski IW. Necrotizing fasciitis: early sonographic diagnosis. J Clin Ultrasound 2011;39:236-9. Review/Other-Dx 1 case report To report a case of necrotizing fasciitis affecting the right upper extremity after a venipuncture that was diagnosed early based on sonographic findings. No results stated in abstract. 4
63. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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