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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Dodwell ER.. Osteomyelitis and septic arthritis in children: current concepts. [Review]. Curr Opin Pediatr. 25(1):58-63, 2013 Feb. Review/Other-Dx N/A To review the cause, epidemiology, diagnosis, and treatment of osteoarticular infections have changed considerably in recent years. No abstract available. 4
2. Gafur OA, Copley LA, Hollmig ST, Browne RH, Thornton LA, Crawford SE. The impact of the current epidemiology of pediatric musculoskeletal infection on evaluation and treatment guidelines. J Pediatr Orthop 2008;28:777-85. Review/Other-Dx 554 children The purpose was (1) to compare the current epidemiology of musculoskeletal infection with historical data at the same institution 20 years prior and (2) to evaluate the spectrum of the severity of this disease process within the current epidemiology. Five hundred fifty-four children were studied (osteomyelitis, n = 212; septic arthritis, n = 118; pyomyositis, n = 20; and deep abscess, n = 204). The annualized per capita incidence of osteomyelitis increased 2.8-fold, whereas that of septic arthritis was unchanged when compared with historical data from 20 years prior. Methicillin-resistant Staphylococcus aureus was isolated as the causative organism in 30% of the children. We identified increasing severity of illness according to a hierarchy of tissue involvement (osteomyelitis > septic arthritis > pyomyositis > abscess) and according to the identification of contiguous infections within in each primary diagnostic category. 4
3. Jaramillo D.. Infection: musculoskeletal. [Review]. Pediatr Radiol. 41 Suppl 1:S127-34, 2011 May. Review/Other-Dx N/A Review imaging approach to osteomyelitis. MRI has become the advanced imaging modality of choice in osteomyelitis. There is an increasing understanding of the appropriate role for gadolinium enhancement, which is not indicated when the pre-gadolinium images are normal. Other related infections, including pyomyositis, are best imaged with MRI. 4
4. Riise OR, Kirkhus E, Handeland KS, et al. Childhood osteomyelitis-incidence and differentiation from other acute onset musculoskeletal features in a population-based study. BMC Pediatr 2008;8:45. Observational-Dx 473 patients To assess the annual incidence of osteomyelitis in children, describe the patient and disease characteristics in those with acute (< 14 days disease duration) and subacute osteomyelitis (> or = 14 days disease duration), and differentiate osteomyelitis patients from those with other acute onset musculoskeletal features. The total annual incidence rate of osteomyelitis was 13 per 100,000 (acute osteomyelitis 8 and subacute osteomyelitis 5 per 100,000). The incidence was higher in patients under the age of 3 than in older children (OR 2.9, 95%: CI 2.3-3.7). The incidence of non-vertebral osteomyelitis was higher than the incidence of vertebral osteomyelitis (10 vs. 3 per 100 000; p = .002). Vertebral osteomyelitis was more frequent in girls than in boys (OR 7.0, 95%: CI 3.3-14.7). ESR > or = 40 mm/hr had the highest positive predictive laboratory value to identify osteomyelitis patients at 26% and MRI had a positive predictive value of 85%. Long-bone infection was found in 16 (43%) patients. ESR, CRP, white blood cell count, neutrophils and platelet count were higher for patients with acute osteomyelitis than for patients with subacute osteomyelitis. Subacute findings on MRI and doctor's delay were more common in subacute osteomyelitis than in acute osteomyelitis patients. Blood culture was positive in 26% of the acute osteomyelitis patients and was negative in all the subacute osteomyelitis patients. 2
5. Chen WL, Chang WN, Chen YS, et al. Acute community-acquired osteoarticular infections in children: high incidence of concomitant bone and joint involvement. J Microbiol Immunol Infect 2010;43:332-8. Review/Other-Dx 27 children To provides recent clinical experiences on acute community-acquired osteoarticular infections in children in Taiwan. We enrolled 27 children in our study, and reviewed 692 patients reported from six major studies in Taiwan. Of the 27 patients, 15 (55.6%) had concomitant bone and joint involvement. Blood cultures were positive in 44.4% of the children in this study and 48–52% in the other studies. Pathogens could be identified in 66.7% of our children and 63–76% in the other studies, when surgical specimens were available for culture. Staphylococcus aureus was consistently the most common pathogen found in all studies. Of the S. aureus isolates, methicillin-resistant S. aureus accounted for 13.3% in our study and 22–24% in the others. 4
6. Monsalve J, Kan JH, Schallert EK, Bisset GS, Zhang W, Rosenfeld SB. Septic arthritis in children: frequency of coexisting unsuspected osteomyelitis and implications on imaging work-up and management. AJR Am J Roentgenol. 204(6):1289-95, 2015 Jun. Review/Other-Dx 162 children To evaluate the demographic distribution of septic arthritis and osteomyelitis in children and to explore optimal imaging guidelines for these patients. One hundred sixty-two children who underwent 177 MRI examinations were diagnosed with acute musculoskeletal infection. One hundred three patients were included in the septic arthritis category, of whom 70 (68%) had septic arthritis with osteomyelitis. Seventy-four (42.1%) patients had isolated osteomyelitis without septic arthritis. Children under 2 years old were more likely to have septic arthritis (either isolated or with osteomyelitis) than isolated osteomyelitis compared with older children (p = 0.0003). 4
7. Rosenfeld S, Bernstein DT, Daram S, Dawson J, Zhang W. Predicting the Presence of Adjacent Infections in Septic Arthritis in Children. J Pediatr Orthop. 36(1):70-4, 2016 Jan. Observational-Dx 87 patients To develop a prediction algorithm to distinguish septic arthritis with adjacent infections from isolated septic arthritis to determine which patients should undergo preoperative MRI. A total of 36 (41%) patients had isolated septic arthritis and 51 (59%) had septic arthritis with adjacent foci. Five variables (age above 3.6 y, CRP>13.8 mg/L, duration of symptoms >3 d, platelets <314×10 cells/µL, and ANC>8.6×10 cells/µL) were found to be predictive of adjacent infection and were included in the algorithm. Patients with =3 risk factors were classified as high risk for septic arthritis with adjacent infection (sensitivity: 90%, specificity: 67%, positive predictive value: 80%, negative predictive value: 83%). 3
8. Guillerman RP.. Osteomyelitis and beyond. Pediatr Radiol. 43 Suppl 1:S193-203, 2013 Mar. Review/Other-Dx N/A To focuss on the imaging characteristics of osteomyelitis, septic arthritis and pyomyositis and the differentiating features of potential mimics of infection. No results listed in abstract. 4
9. Jaimes C, Chauvin NA, Delgado J, Jaramillo D. MR imaging of normal epiphyseal development and common epiphyseal disorders. Radiographics 2014;34:449-71. Review/Other-Dx N/A To review the normal structure of the epiphysis, its appearance at MR imaging, and age-related changes to the epiphysis. No results stated in the abstract. 4
10. Gilbertson-Dahdal D, Wright JE, Krupinski E, McCurdy WE, Taljanovic MS. Transphyseal involvement of pyogenic osteomyelitis is considerably more common than classically taught. AJR Am J Roentgenol. 203(1):190-5, 2014 Jul. Observational-Dx 32 patients To document our observation that pyogenic osteomyelitis crosses the growth plate more frequently in the pediatric patient population than is classically taught. Of 32 subjects, 81% showed transphyseal infection. In our study, the z test revealed that transphyseal infection occurred significantly more often than what would be considered rare (z = 4.75, p < 0.01). 3
11. Dolitsky R, DePaola K, Fernicola J, Collins C. Pediatric Musculoskeletal Infections. Pediatr Clin North Am 2020;67:59-69. Review/Other-Dx N/A To discuss the range in presentation for pediatric musculoskeletal infections. No results stated in the abstract. 4
12. Sadat-Ali M. The status of acute osteomyelitis in sickle cell disease. A 15-year review. Int Surg 1998;83:84-7. Review/Other-Tx 201 patients To present a 15 year review of the status of acute osteomyelitis in sickle cell disease and to assess the type of infection, infecting organism, mode of treatment and complications. Two-hundred and one patients were treated for acute osteomyelitis in sickle cell disease. These patients had 327 episodes. There were 125 males and 76 females with a mean age of 9.6 years (range 6 months to 33 years). Forty-eight (23.8%) patients had multifocal infection. The most common infecting organism was salmonella species in 84 patients (41.7%) and 71/84 patients were below the age of 12 years. In 39/45 patients who as children grew salmonella species initially had acute osteomyelitis due to other organisms in adult life. In 41 patients more than one organism was cultured and in 11 patients the pus/medullary canal fluid did not grow any organism. Blood culture grew infective organism in 46.80%. Tibia was the commonest site of infection 76/201. The incidence of chronic osteomyelitis was 2.48%. 4
13. Jaramillo D, Dormans JP, Delgado J, Laor T, St Geme JW 3rd. Hematogenous Osteomyelitis in Infants and Children: Imaging of a Changing Disease. [Review]. Radiology. 283(3):629-643, 2017 06. Review/Other-Dx N/A To provide an overview of the imaging implications directed by the changing epidemiology, the newer insights of anatomy and pathophysiology, the imaging characteristics with emphasis on specific locations and disease complications, and the differential diagnosis considerations in hematogenous osteomyelitis in infants and children. No results stated in the abstract. 4
14. Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am. 1999; 81(12):1662-1670. Observational-Dx 282 patients Retrospective review to determine the diagnostic value of presenting variables for differentiating between septic arthritis and transient synovitis of the hip in children and to develop an evidence-based clinical prediction algorithm for this differentiation. 4 independent multivariate clinical predictors were identified to differentiate between septic arthritis and transient synovitis: history of fever, non-weight-bearing, ESR of at least 40 millimeters per hour, and serum white blood-cell count of more than 12,000 cells per cubic millimeter (12.0 x 10(9) cells per liter). The predicted probability of septic arthritis was determined for all 16 combinations of these 4 predictors and is summarized as <0.2% for zero predictors, 3.0% for one predictor, 40.0% for two predictors, 93.1% for three predictors, and 99.6% for four predictors. The chi-square test for trend and the AUC indicated excellent diagnostic performance of this group of multivariate predictors in identifying septic arthritis. Although several variables differed significantly between the group that had septic arthritis and the group that had transient synovitis, substantial overlap in the intermediate ranges made differentiation difficult on the basis of individual variables alone. However, by combining variables, the authors were able to construct a set of independent multivariate predictors that, together, had excellent diagnostic performance in differentiating between septic arthritis and transient synovitis of the hip in children. 3
15. Caird MS, Flynn JM, Leung YL, Millman JE, D'Italia JG, Dormans JP. Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study. J Bone Joint Surg Am. 2006; 88(6):1251-1257. Observational-Dx 53 children Prospective collection of data to determine factors distinguishing septic arthritis from transient synovitis of the hip in children. Fever, an elevated C-reactive protein level, an elevated ESR, non-weight-bearing, and an elevated serum white blood-cell count were predictors of septic arthritis. The probability of septic arthritis was estimated to be 98% when five predictors were present, 93% when four predictors were present and 83% when three predictors were present. 3
16. Ernat J, Riccio AI, Fitzpatrick K, Jo C, Wimberly RL. Osteomyelitis is Commonly Associated With Septic Arthritis of the Shoulder in Children. J Pediatr Orthop. 37(8):547-552, 2017 Dec. Observational-Dx 22 children To describe the clinical presentation, management, and outcomes of surgically treated septic arthritis of the shoulder in a pediatric population. A total of 22 children, ages 15 days to 14 years (average 37.3 mo), were treated for septic arthritis of the shoulder from 2006 to 2010 at a single pediatric institution. All patients were managed with open anterior arthrotomy at an average of 1.95 days after initial orthopaedic consultation (range, 0 to 15 d). Multiple presenting signs were noted; the most common was decreased use (59%). Average admission laboratory values include C-reactive protein 10.6 (range, 0.3 to 41.6), erythrocyte sedimentation rate 62.8 (range, 11 to 107), and white blood cell count 14.9 (range, 5.9 to 31.7). Initial radiographs were read as normal in 12 patients, concern for osteomyelitis in 5, cortical irregularity in 4, effusion in 3, and neoplasm in a single child. Nineteen patients had a preoperative magnetic resonance imaging and 15 demonstrated an effusion, 15 had evidence of humeral osteomyelitis, 5 had a subperisoteal abscess, and 4 had soft tissue abscesses. Eight patients remained culture negative. The most commonly identified organism was methcillin-resistant Staphylococcus aureus (MRSA) (22.7%). The patients under 12 months of age revealed more diverse organisms at culture and were less likely to have MRSA. All patients averaged 1.55 (range, 1 to 5) surgical procedures and had an average hospital stay of 13.5 days. Intravenous antibiotics averaged 16.3 days followed by an average of 34 days of oral treatment. MRSA patients were significantly more likely to require multiple operations to eradicate the infection (P<0.02) and had a longer duration of intravenous antibiotic use (P<0.003). MRSA patients were more likely to have abnormal radiographs at final follow-up (P<0.03). 3
17. Manz N, Krieg AH, Heininger U, Ritz N. Evaluation of the current use of imaging modalities and pathogen detection in children with acute osteomyelitis and septic arthritis. Eur J Pediatr. 177(7):1071-1080, 2018 Jul. Observational-Dx 96 patients To investigate how recent advances such as better availability of MRI and the emergence of other pathogens have influenced diagnosis and the management of patients with acute osteomyelitis (OM) and septic arthritis (SA) at our institution more recently. Ninety-six children were identified: OM, n = 45; SA, n = 42; and OM + SA, n = 9. Diagnostic imaging was performed in100% of OM or OM + SA and 95% of SA patients. MRI was performed in 85% of OM patients, 26% of SA patients and 100%OM + SA patients. In patients with OM or SA, concomitant joint/bone involvement was detected in 24 and 36% of patients,respectively. In 58% of patients, a pathogen was detected (Staphylococcus aureus, Streptococcus pyogenes and Streptococcuspneumoniae being most common). Blood and tissue culture were positive in 41 and 86% for OM patients and in 14 and 41%,respectively, for SA patients. In 42% of patients, no pathogen was identified, of which 40% had no material for blood or tissueculture/NAT taken. 3
18. Nduaguba AM, Flynn JM, Sankar WN. Septic Arthritis of the Elbow in Children: Clinical Presentation and Microbiological Profile. J Pediatr Orthop. 36(1):75-9, 2016 Jan. Review/Other-Dx 12 children To describe the clinical presentation and diagnostic findings, associated pathology, and microbiological profile of septic arthritis of the elbow in a pediatric population. Twelve children underwent diagnostic arthrocentesis of the elbow joint for septic arthritis at an average age of 6 years and 9 months (range, 2 mo to 13 y and 7 mo). Every child had pain, localized erythema and edema, and restricted range of motion; 10/12 were febrile. Mean duration of symptoms prior to joint tap was 4 days (range, 1 to 14 d). Concurrent osteomyelitis was found in 7 patients, as confirmed with magnetic resonance imaging (MRI): 5 at initial presentation and 2 after readmission for persistent symptoms. Causative pathogens were MSSA (7), MRSA (2), Group G streptococcus (1), Pseuodomonas aureginosa (1), and Streptococcus pneumonia (1). ESR was >40 mm/h in 8/11 patients, CRP was >2 mg/dL in all patients, and synovial WBC count was >50,000 cells/mm3 in 8/9 patients. One patient developed fulminant sepsis during hospitalization and 2 children were readmitted within 30 days of discharge for unrecognized osteomyelitis and/or recurrence of septic arthritis of the elbow. 4
19. Refakis CA, Arkader A, Baldwin KD, Spiegel DA, Sankar WN. Predicting Periarticular Infection in Children With Septic Arthritis of the Hip: Regionally Derived Criteria May Not Apply to All Populations. Journal of Pediatric Orthopedics. 39(5):268-274, 2019 May/Jun. Observational-Dx 51 patients To determine the applicability of recently published predictive criteria for periarticular infections (PAIs) (developed in the Southwestern United States using a variety of joints) to septic arthritis of the hip treated at a large Northeastern tertiary care center. Fifty-one subjects (53 hips) were identified with a mean age of 7.0 years (range, 1.2 to 19.3 y) and mean follow-up was 16 months (range, 2 to 85 mo). MRIs were obtained in 20 subjects (43%). Coexisting osteomyelitis was revealed in 7/20 of these studies (35% of MRIs); 4 of which showed coexisting intramuscular abscesses. Within our MRI cohort, the Rosenfeld criteria were found to have a sensitivity of 86%, a specificity of 54%, and a false-positive rate of 50% for the hip (compared with originally reported sensitivity of 90%, specificity of 67%, and false-positive rate of 33%). Overall, advanced imaging changed management in 5/51 patients (9%) by influencing the need for further treatment, whereas the remainder underwent isolated treatment of the septic hip joint with no adverse outcomes. One patient in the MRI cohort (without PAI) developed osteonecrosis of the femoral head. 3
20. Schallert EK, Kan JH, Monsalve J, Zhang W, Bisset GS 3rd, Rosenfeld S. Metaphyseal osteomyelitis in children: how often does MRI-documented joint effusion or epiphyseal extension of edema indicate coexisting septic arthritis?. Pediatr Radiol. 45(8):1174-81, 2015 Jul. Observational-Dx 51 patients To determine the incidence of epiphyseal marrow edema, joint effusions, perisynovial edema and epiphyseal non-enhancement in the setting of pediatric metaphyseal osteomyelitis and whether this may be used to predict coexisting septic arthritis. One hundred and three joints with metaphyseal osteomyelitis were identified (mean age: 7.1 years; M:F 1.3:1), of whom 53% (55/103) had joint effusions, and of those, 75% (41/55) had surgically confirmed septic arthritis. The incidence of coexisting septic arthritis was 40% in the setting of epiphyseal edema, 74% in epiphyseal edema and effusion, 75% with perisynovial edema, 76% with epiphyseal non-enhancement and 77% when all four variables were present. Of these, the only statistically significant variable, however, was the presence of a joint effusion with a P-value of <0.0001 via Fisher exact test. Statistical significance for coexisting septic arthritis was also encountered when cases were subdivided into intra-articular vs. extra-articular metaphyses (P-value = 0.0499). No statistically significant difference was found between patients younger than 24 months and those older than 24 months. 3
21. Montgomery NI, Epps HR. Pediatric Septic Arthritis. [Review]. Orthop Clin North Am. 48(2):209-216, 2017 Apr. Review/Other-Dx N/A To discuss treatments and recommendations for pediatric septic arthritis. No results in the abstract. 4
22. Booth TN, Iyer RS, Falcone RA, Jr., et al. ACR Appropriateness Criteria® Back Pain-Child. J Am Coll Radiol 2017;14:S13-S24. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for back pain in a child. No results stated in abstract. 4
23. Barrett JF, Keat N. Artifacts in CT: recognition and avoidance. Radiographics 2004;24:1679-91. Review/Other-Dx N/A To discuss ways to optimize image quality by recognizing and avoiding artifacts found in computed tomography (CT). No results stated in the abstract. 4
24. Katsura M, Sato J, Akahane M, Kunimatsu A, Abe O. Current and Novel Techniques for Metal Artifact Reduction at CT: Practical Guide for Radiologists. Radiographics 2018;38:450-61. Review/Other-Dx N/A To discuss current and novel techniques of several artifact reduction methods introduced in modern computed tomography (CT) systems. No results stated in the abstract. 4
25. Talbot BS, Weinberg EP. MR Imaging with Metal-suppression Sequences for Evaluation of Total Joint Arthroplasty. [Review]. Radiographics. 36(1):209-25, 2016 Jan-Feb. Review/Other-Dx N/A To discuss magnetic resonance (MR) imaging with metal-suppression sequences as a tool in the detection of arthroplasty-related complications. No results stated in the abstract. 4
26. Frank G, Mahoney HM, Eppes SC. Musculoskeletal infections in children. Pediatr Clin North Am. 2005; 52(4):1083-1106, ix. Review/Other-Dx N/A Review musculoskeletal infection in children. Serious musculoskeletal infections in children include osteomyelitis, septic arthritis, pyomyositis, and necrotizing fasciitis. The epidemiology, pathophysiology, and microbiology of each of these infections are reviewed. Specific diagnostic studies and management strategies are discussed. Prompt recognition and treatment is emphasized to prevent potential long-term sequelae. 4
27. Safdar NM, Rigsby CK, Iyer RS, et al. ACR Appropriateness Criteria® Acutely Limping Child Up To Age 5. J Am Coll Radiol 2018;15:S252-S62. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for acutely limping child up to age 5. No results stated in abstract. 4
28. Erdman WA, Tamburro F, Jayson HT, Weatherall PT, Ferry KB, Peshock RM. Osteomyelitis: characteristics and pitfalls of diagnosis with MR imaging. Radiology 1991;180:533-9. Observational-Dx 110 patients To report the characteristics and pitfalls of osteomyelitis diagnosis with Magnetic Resonance Imaging. Diagnostic criteria of dark marrow on T1-weighted images and bright marrow on short-tau inversion-recovery images yielded a prospective sensitivity of 98% and a prospective specificity of 75%. Sixty percent of uncomplicated septic joint effusions demonstrated abnormal marrow signal intensity that was mistaken for osteomyelitis. Retrospective review revealed that overall specificity could be improved to 82% without loss of sensitivity if increased marrow signal intensity on T2-weighted images were included as an additional criterion. Specificity may be further increased by use of knowledge of morphologic patterns that distinguish various forms of osteomyelitis. Ten patients (9%) had potential pitfall diagnoses (eg, fracture, infarction, healed infection) that mimic osteomyelitis. 2
29. Jaramillo D, Treves ST, Kasser JR, Harper M, Sundel R, Laor T. Osteomyelitis and septic arthritis in children: appropriate use of imaging to guide treatment. AJR Am J Roentgenol 1995;165:399-403. Review/Other-Dx N/A To define the use of imaging in cases of osteomyelitis and septic arthritis in children in specific clinical scenarios in which additional information is likely to lead to management modification. No results stated in the abstract. 4
30. Karmazyn B.. Imaging approach to acute hematogenous osteomyelitis in children: an update. [Review] [28 refs]. Semin Ultrasound CT MR. 31(2):100-6, 2010 Apr. Review/Other-Dx N/A To discuss the current multimodality imaging approach for early diagnosis of acute hematogenous osteomyelitis (AHOM), and evaluation of complications to guide treatment. No results listed in abstract. 4
31. Pineda C, Vargas A, Rodriguez AV. Imaging of osteomyelitis: current concepts. Infect Dis Clin North Am 2006;20:789-825. Review/Other-Dx N/A To discuss the current concepts of the imaging of osteomyelitis. No results stated in the abstract. 4
32. Markhardt BK, Woo K, Nguyen JC. Evaluation of suspected musculoskeletal infection in children over 2 years of age using only fluid-sensitive sequences at MRI. Eur Radiol. 29(10):5682-5690, 2019 Oct. Observational-Dx 52 boys, 36 girls To evaluate whether an magnetic resonance imaging (MRI) protocol with only fluid-sensitive sequences can be used to evaluate for musculoskeletal (MSK) infection of the pelvis and limbs in children. Interreader agreement for both types of studies had kappa values between 0.86 and 1. For the assessment of MSK infection, the fluid-sensitive study had 100% sensitivity and 61.3% specificity, with 84.8% interreader agreement; and the CE study had 100% sensitivity and 71.0% specificity, with 88.6% interreader agreement. All cases of septic arthritis (13 cases) and osteomyelitis (25 cases) were identified as possible infection or infection until proven otherwise (negative predictive value 100%) with 100% interreader agreement on fluid-sensitive sequences. 2
33. Delgado J, Bedoya MA, Green AM, Jaramillo D, Ho-Fung V. Utility of unenhanced fat-suppressed T1-weighted MRI in children with sickle cell disease -- can it differentiate bone infarcts from acute osteomyelitis?. Pediatr Radiol. 45(13):1981-7, 2015 Dec. Observational-Dx 20 boys, 11 girls To evaluate the reliability of unenhanced T1-W fat-saturated magnetic resonance imaging (MRI) for differentiation between bone infarcts and acute osteomyelitis in children with sickle cell disease (SCD). Based on the clinical standard, 5 children were classified as positive for osteomyelitis and 26 children as positive for bone infarct (negative for osteomyelitis). The bone marrow signal intensity on T1-W fat-saturated imaging was not significant for the differentiation between bone infarct and osteomyelitis (P = 0.56). None of the additional evaluated imaging parameters on unenhanced MRI proved reliable in differentiating these diagnoses. 2
34. Ahmad S, Khan ZA, Rehmani R, Sheikh MY. Diagnostic dilemma in sicklers with acute bone crisis: role of subperiosteal fluid collection on MRI in resolving this issue. JPMA J Pak Med Assoc. 60(10):819-22, 2010 Oct. Review/Other-Dx 59 patients To establish magnetic resonance imaging (MRI) criteria to diagnose early osteomyelitis in sickle cell disease patients with acute bone crisis and to differentiate it from normally occurring ischaemic changes in these patients. Depending on MRI diagnostic criteria, we diagnosed 32 cases for osteomyelitis. In 26 patients diagnosis was confirmed microbiologically while 6 patients were treated on clinico radiological basis which showed marked improvement on follow up. Five patients with osteomyelitis had established MR features of osteomyelitis while in 27 cases the diagnosis was made on the basis of presence of subperiosteal fluid. 4
35. Henninger B, Glodny B, Rudisch A, et al. Ewing sarcoma versus osteomyelitis: differential diagnosis with magnetic resonance imaging. Skeletal Radiol. 42(8):1097-104, 2013 Aug. Observational-Dx 28 patients To find and evaluate characteristic magnetic resonance imaging (MRI) patterns for the differentiation between Ewing sarcoma and osteomyelitis. The most clear-cut pattern for determining the correct diagnosis was the presence of a sharp and defined margin of the bone lesion, which was found in all patients with Ewing sarcoma, but in none of the patients with osteomyelitis (P < 0.0001). Contrast enhancing soft tissue was present in all cases with Ewing sarcoma and absent in 4 patients with osteomyelitis (P = 0.0103). Cortical destruction was found in all patients with Ewing sarcoma, 4 patients with osteomyelitis did not present any cortical reaction (P = 0.0103). Cystic or necrotic areas were identified in 13 patients with Ewing sarcoma and in 1 patient with osteomyelitis (P = 0.004). Interobserver reliability was very good (kappa = 1) in Ewing sarcoma and moderate (kappa = 0.6) in patients with osteomyelitis. 2
36. McCarville MB, Chen JY, Coleman JL, et al. Distinguishing Osteomyelitis From Ewing Sarcoma on Radiography and MRI. AJR Am J Roentgenol. 205(3):640-50; quiz 651, 2015 Sep. Observational-Dx 63 patients The purpose of this study was to determine whether clinical and imaging features can distinguish osteomyelitis from Ewing sarcoma (EWS) and to assess the accuracy of percutaneous biopsy versus open biopsy in the diagnosis of these diseases. On radiography, the presence of joint or metaphyseal involvement, a wide transition zone, a Codman triangle, a periosteal reaction, or a soft-tissue mass, when tested individually, was more likely to be noted in subjects with EWS (p = 0.05) than in subjects with osteomyelitis. On MRI, permeative cortical involvement and soft-tissue mass were more likely in subjects with EWS (p = 0.02), whereas a serpiginous tract was more likely to be seen in subjects with osteomyelitis (p = 0.04). African Americans were more likely to have osteomyelitis than EWS (p = 0). According to the results of multiple regression analysis, only ethnicity and soft-tissue mass remained statistically significant (p = 0.01). The findings from 100% of open biopsies (18/18) and 58% of percutaneous biopsies (7/12) resulted in the diagnosis of osteomyelitis, whereas the findings from 88% of open biopsies (22/25) and 50% of percutaneous biopsies (3/6) resulted in a diagnosis of EWS. 2
37. Averill LW, Hernandez A, Gonzalez L, Pena AH, Jaramillo D. Diagnosis of osteomyelitis in children: utility of fat-suppressed contrast-enhanced MRI. AJR Am J Roentgenol. 2009; 192(5):1232-1238. Observational-Dx 78 skeletally immature children and adolescents To retrospectively determine whether the use of fat-suppressed contrast-enhanced MRI, compared with unenhanced MRI alone increases reader confidence in the diagnosis of osteomyelitis and its complications in children. Osteomyelitis was clinically diagnosed in 40 cases (51%). There was no significant difference between the sensitivity and specificity of unenhanced MRI (P=1.0) and those of contrast-enhanced MRI (P=0.77) for the diagnosis of osteomyelitis. Nonetheless, there was a significant (P<0.001) increase in confidence in the diagnosis of osteomyelitis and its complications. This increase in confidence was most pronounced for the diagnosis of abscess (46%). The addition of contrast enhancement was least useful in findings deemed definitely absent on unenhanced MR images. Although it does not increase the sensitivity or specificity of the diagnosis, use of contrast-enhanced MRI does increase reader confidence in the diagnosis of osteomyelitis and its complications in cases in which bone or soft-tissue edema is found on unenhanced images. In the clear absence of edema on unenhanced images, however, contrast enhancement is not needed. 3
38. 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
39. Kim EY, Kwack KS, Cho JH, Lee DH, Yoon SH. Usefulness of dynamic contrast-enhanced MRI in differentiating between septic arthritis and transient synovitis in the hip joint. AJR Am J Roentgenol. 198(2):428-33, 2012 Feb. Observational-Dx 18 patients To show the usefulness of dynamic contrast-enhanced MRI (DCE-MRI) and to determine the optimal time window in MRI for differentiating between septic arthritis and transient synovitis in painful hip joints. Six of seven patients with septic arthritis in the hip joint had decreased enhancement during the early phase of DCE-MRI. The enhancement difference between the two patient groups was statistically significant (p = 0.0498). The time at the maximal difference in the signal intensity between two time-signal intensity curves of both femoral heads was approximately 3.5 minutes. The area under the receiver operating characteristic curve for predicting septic arthritis was 0.792. 3
40. Merlini L, Anooshiravani M, Ceroni D. Concomitant septic arthritis and osteomyelitis of the hip in young children; a new pathophysiological hypothesis suggested by MRI enhancement pattern. BMC med. imaging. 15:17, 2015 May 19. Review/Other-Dx 10 patients To elaborate a physiopathological hypothesis based on the peculiar magnetic resonance imaging (MRI) findings to explain the onset of acute haematogenous osteomyelitis (AHO) after septic arthritis (SA). Ten patients met the inclusion criteria. Six (1-11 months) demonstrated, on the initial MRI, decreased perfusion on gadolinium enhanced fat-suppressed T1-weighted sequence of the femoral epiphysis and developed one month later metaphyseal AHO. Four (5-14 years) did not show decreased perfusion and did not develop AHO on follow-up. The type of germ involved influenced neither the type of enhancement pattern nor the outcome. 4
41. Browne LP, Guillerman RP, Orth RC, Patel J, Mason EO, Kaplan SL. Community-acquired staphylococcal musculoskeletal infection in infants and young children: necessity of contrast-enhanced MRI for the diagnosis of growth cartilage involvement. AJR Am J Roentgenol. 198(1):194-9, 2012 Jan. Observational-Dx 25 patients To assess the diagnostic efficacy of contrast-enhanced and unenhanced MRI sequences for the diagnosis of community-acquired S. aureus extremity skeletal infection in infants and young children. Community-acquired S. aureus skeletal infections were noted in 34 extremity sites in 25 patients, five of whom had more than one site of disease. The affected skeletal sites were metaphyseal or metadiaphyseal bone marrow only in 16 cases (47%), unossified growth cartilage only in nine cases (26%), and both the unossified growth cartilage and metaphyseal or metadiaphyseal bone marrow in nine cases (26%). In seven of the nine cases of isolated involvement of the unossified growth cartilage, the cartilage appeared normal on unenhanced sequences and the diagnosis was made only by the demonstration of hypoenhancing or nonenhancing foci in the cartilage after gadolinium-based contrast agent administration. In five of the nine cases of infection of both the unossified growth cartilage and metaphyseal or metadiaphyseal bone marrow, neither the cartilage nor bone marrow appeared abnormal on unenhanced sequences. Therefore, 12 cases of skeletal infection would have been missed without the inclusion of contrast-enhanced sequences. Follow-up extremity radiographs were available for 10 patients, eight (80%) of whom exhibited growth disturbances. 2
42. Johnson DP, Hernanz-Schulman M, Martus JE, Lovejoy SA, Yu C, Kan JH. Significance of epiphyseal cartilage enhancement defects in pediatric osteomyelitis identified by MRI with surgical correlation. Pediatr Radiol. 41(3):355-61, 2011 Mar. Observational-Dx 13 children To evaluate the incidence and clinical impact of epiphyseal cartilage enhancement defects (ED) in pediatric epiphyseal osteomyelitis (OM). Study and control ED were respectively present in 10/14 (71.4%-6 global, 4 focal) and 6/28 (21.4%-0 global, 6 focal), P=0.0017. An analysis of ED patterns between study and control patients showed significant difference for global (P=0.0006), but no difference for focal ED (P=0.71). For the six study epiphyses with global ED, epiphyseal abscesses were present in two (33.3%). For the four study epiphyses with focal ED, epiphyseal abscesses were present in two (50%). For the controls, no abnormalities were found on follow-up of epiphyses with focal ED. 2
43. Metwalli ZA, Kan JH, Munjal KA, Orth RC, Zhang W, Guillerman RP. MRI of suspected lower extremity musculoskeletal infection in the pediatric patient: how useful is bilateral imaging?. AJR. American Journal of Roentgenology. 201(2):427-32, 2013 Aug. Observational-Dx 165 patients To determine the frequency of bilateral abnormalities in children with suspected lower extremity musculoskeletal infection and the impact of detection of contralateral abnormalities by MRI on patient management. The MRI examination was normal in 2% (4/165). Osteomyelitis was diagnosed in 33% (54/165) of the MRI examinations; among these examinations 20% (11/54) had both ipsilateral septic arthritis and osteomyelitis, 2% (1/54) had bilateral osteomyelitis, and 67% (111/165) of the examinations were negative for osteomyelitis. Bilateral abnormalities were detected in 20% (22/111) of patients without osteomyelitis, with 18% (4/22) presenting with bilateral signs or symptoms. Abnormalities in the contralateral extremity included myositis (18%, 4/22), stress reaction (18%, 4/22), subcutaneous edema (18%, 4/22), leukemia (14%, 3/22), reactive joint effusion (14%, 3/22), Baker cyst (5%, 1/22), and osteonecrosis (5%, 1/22). Identification of clinically unsuspected abnormalities of the contralateral extremity by MRI was not associated with alterations in medical or surgical management in children with or without osteomyelitis. 2
44. Lindsay AJ, Delgado J, Jaramillo D, Chauvin NA. Extended field of view magnetic resonance imaging for suspected osteomyelitis in very young children: is it useful?. Pediatr Radiol. 49(3):379-386, 2019 03. Observational-Dx 51 children To determine if extended field of view (FOV) MRI contributes important information in young children with suspected osteomyelitis. We studied 51 children with a mean age of 2.2 years (range: 21 days-5.5 years); 53% were boys. Osteomyelitis was depicted by MRI in 20 subjects (39.2%). Survey coronal fluid-sensitive imaging was accomplished by adding a single fluid-sensitive series in 1 child, 2 series in 31 children, 3 series in 16 children and 4 series in 3 children. Survey imaging added a median total time of 6:51 min to the examination (range: 2.29-20.54 min). Extended FOV imaging added important information in 11/51 subjects (21.6%), in 6 cases (11.8%) of infection and in 5 cases (9.8%) by suggesting alternative diagnoses. 2
45. Nguyen JC, Lee KS, Thapa MM, Rosas HG. US Evaluation of Juvenile Idiopathic Arthritis and Osteoarticular Infection. [Review]. Radiographics. 37(4):1181-1201, 2017 Jul-Aug. Review/Other-Dx N/A To review the use of pediatric musculoskeletal US (pediatric-specific guidelines and useful techniques), changes related to skeletal maturation, and US findings that can be seen with juvenile idiopathic arthritis and osteoarticular infection, with an emphasis on the advantages (dynamic, Doppler, and multifocal assessments) and limitations (inability to evaluate the bone marrow) of US. No results stated in the abstract. 4
46. Tordjman D, Holvoet L, Benkerrou M, et al. Hematogenous osteoarticular infections of the hand and the wrist in children with sickle cell anemia: preliminary report. J Pediatr Orthop. 34(1):123-8, 2014 Jan. Experimental-Dx 34 children To report on hematogenous osteoarticular infections of the hand and the wrist in children with sickle cell anemia. The most common site of osteomyelitis for the sickle cell group was the metacarpals and the fingers phalanx (87.5%) whereas the most common site for the control group was the wrist and the carpus (96.2%; P<0.005).The most common pathogens responsible for osteomyelitis was Salmonella sp. (37.5%) for children with SCD, whereas it was Staphylococcus aureus (70%) for the nonsicklers. There was a significant difference between both groups regarding the treatment. Indeed, a surgical procedure was needed for the sickle cell group in all cases (100%) whereas a surgical debridement was needed in only 19.2% patients in the control group (P<0.001). At long-term follow-up, there were more long-term complications in the sickle cell group (62.5%) with epiphysiodesis of the metacarpals and metacarpophalangeal joint destruction whereas only 11.5% cases with complications were present in the control group including distal ulna epiphysiodesis, proximal interphalangeal joint stiffness, and a central radius epiphysiodesis (P<0.004). 2
47. Volberg FM, Sumner TE, Abramson JS, Winchester PH. Unreliability of radiographic diagnosis of septic hip in children. Pediatrics 1984;74:118-20. Review/Other-Dx N/A To analyze the radiographs of 19 pediatric patients with aspiration-proven bacterial infections of the hip. The hip radiograph was abnormal in all neonates showing lateral subluxation. The radiograph was negative in eight of ten children more than 1 year of age. 4
48. Zawin JK, Hoffer FA, Rand FF, Teele RL. Joint effusion in children with an irritable hip: US diagnosis and aspiration. Radiology. 1993; 187(2):459-463. Observational-Dx 96 children To determine if the combination of orthopedic evaluation, diagnostic US, and US-guided hip aspiration in children with an irritable hip could indicate those children with septic arthritis, thus decreasing the number exposed to operative intervention, and shorten the anesthesia time. Patients were prospectively enrolled in a protocol. Clinical evaluation, radiographs, and US together determined the need for US-guided aspiration. US-guided aspiration allowed selection of only those with septic arthritis for operative drainage and shortened that procedure. Negative US allow exclusion of septic arthritis but not osteomyelitis. 4
49. Zieger MM, Dorr U, Schulz RD. Ultrasonography of hip joint effusions. Skeletal Radiol 1987;16:607-11. Observational-Dx 123 patients To evaluate the optimal scanning approach and the value of sonography in comparison to X-ray, clinical follow-up, and surgical findings in hip joint effusions. In order to evaluate ultrasonography in patients with suspected hip joint effusions, 123 consecutive patients were examined prospectively. Twenty healthy subjects were used as a control group. The normal sonoanatomy, the recommended scanning approach, and the diagnostic features of intra-articular joint effusions are presented. Even minor fluid collections of 1 or 2 ml could be accurately detected. Transient synovitis and fresh hemorrhagic effusions proved to be echofree, whereas clotted hemorrhagic collections or septic arthritis showed non-echofree effusions. 3
50. Laine JC, Denning JR, Riccio AI, Jo C, Joglar JM, Wimberly RL. The use of ultrasound in the management of septic arthritis of the hip. J Pediatr Orthop B. 24(2):95-8, 2015 Mar. Review/Other-Dx N/A To assess septic arthritis of the hip in a pediatric population. The need for MRI to further evaluate the patient for adjacent infection before treatment is debatable. Once an effusion is confirmed on ultrasonography, we have found that septic arthritis of the hip does not need advanced imaging before arthrotomy and debridement. Patients who fail to clinically respond to an initial hip arthrotomy and appropriate antibiotics may benefit from an MRI for the identification of concomitant infections that may require surgical intervention. 4
51. Gordon JE, Huang M, Dobbs M, Luhmann SJ, Szymanski DA, Schoenecker PL. Causes of false-negative ultrasound scans in the diagnosis of septic arthritis of the hip in children. J Pediatr Orthop. 2002; 22(3):312-316. Observational-Dx 132 children US scans of the hip were performed in children with hip pain during an 18-month period to evaluate the hip for the presence of an effusion. 73 of these patients were followed up long enough to ascertain the presence or absence of septic arthritis. The remaining 59 patients were discharged with diagnoses other than septic arthritis but could not be located to confirm the ultimate accuracy of the diagnosis. Four patients were initially determined to have no effusion but subsequently were diagnosed with septic arthritis (false-negative rate of 5%). Two had inadequate initial US examinations, 2 had US that even on retrospective review did not reveal an effusion. Both of these children had had symptoms for <24 hours, and one had a contralateral hip effusion. Authors recommend using the negative results of an US scan as evidence of the absence of septic arthritis in children with caution when symptoms have been present for <24 hours or when bilateral disease exists. 4
52. Vieira RL, Levy JA. Bedside ultrasonography to identify hip effusions in pediatric patients. Ann Emerg Med. 55(3):284-9, 2010 Mar. Observational-Dx 28 patients To determine whether pediatric emergency physicians can use bedside ultrasonography to accurately identify hip effusions in pediatric patients. Three physicians enrolled patients. Twenty-eight patients were enrolled, and 55 hips were studied. In all hips (both symptomatic and contralateral), bedside ultrasonography had a sensitivity of 80% (95% confidence interval [CI] 51% to 95%), a specificity of 98% (95% CI 85% to 99%), a positive predictive value of 92% (95% CI 62% to 99%), and a negative predictive value of 93% (95% CI 79% to 98%). In the 28 symptomatic hips, bedside ultrasonography had a sensitivity of 85% (95% CI 54% to 97%), a specificity of 93% (95% CI 66% to 99%), a positive predictive value of 92% (95% CI 60% to 99%), and negative predictive value of 88% (95% CI 60% to 98%). When physician self-rated confidence was high, the sensitivity of bedside ultrasonography in symptomatic hips was 90% (95% CI 54% to 99%), the specificity was 100% (95% CI 70% to 100%), the positive predictive value was 100% (95% CI 63% to 100%), and the negative predictive value was 92% (95% CI 62% to 99%). 2
53. Inusa BP, Oyewo A, Brokke F, Santhikumaran G, Jogeesvaran KH. Dilemma in differentiating between acute osteomyelitis and bone infarction in children with sickle cell disease: the role of ultrasound. PLoS ONE. 8(6):e65001, 2013. Observational-Dx 41 patients To assess the additional benefit of C-reactive protein (CRP) and white cell count (WCC) as a tool in aiding early diagnosis in children with sickle cell disease (SCD) presenting acutely with bone pain, fever or swelling. In the osteomyelitis group, USS finding of periosteal elevation and/or fluid collection was reported in 76% cases with the first scan (day 0–6). Overall 84% were diagnosed with USS (initial +repeat). 16% had negative USS. With VOC group, USS showed no evidence of fluid collection in 53/58 admissions (91%), none of the repeated USS showed any fluid collection. Mean C-reactive protein (CRP), and white cell count (WCC) were significantly higher in the OM. 3
54. Mah ET, LeQuesne GW, Gent RJ, Paterson DC. Ultrasonic features of acute osteomyelitis in children. J Bone Joint Surg Br 1994;76:969-74. Review/Other-Dx 38 children To report the ultrasonic features of acute osteomyelitis as the condition evolves and subsequently responds to treatment in children. No abstract available. 4
55. Gilday DL, Paul DJ, Paterson J. Diagnosis of osteomyelitis in children by combined blood pool and bone imaging. Radiology 1975;117:331-5. Observational-Dx N/A No abstract available. No abstract available. 4
56. Howman-Giles R, Uren R. Multifocal osteomyelitis in childhood. Review by radionuclide bone scan. Clin Nucl Med 1992;17:274-8. Review/Other-Dx 136 patients To review radionuclide bone scans and multifocal osteomyelitis in childhood. Over a 3-year period, 136 infants and children who had a final diagnosis of acute osteomyelitis were reviewed, and multifocal osteomyelitis was detected in 27 (19%) patients. The major age peak of acute osteomyelitis was between 6 weeks and 3 years (46%). Two age peaks were found for multifocal disease-less than 6 weeks (38%), and 9 to 12 years (44%). Three patients with multifocal disease had septicemia and photon-deficient areas on bone scans. Another adolescent group had nonspecific bone and joint pain that in some cases persisted for more than 3 months and were finally diagnosed as multifocal osteomyelitis. Organisms were isolated in 15/27 (56%). Multifocal osteomyelitis is well recognized in the neonatel age group. However, it occurs more commonly than previously described in older patients. This higher incidence can most likely be attributed to the higher use of the radionuclide bone scan early in the disease and the high sensitivity of the scan for the detection of osteomyelitis. 4
57. Andersen JB, Mortensen J, Bech BH, Hojgaard L, Borgwardt L. First experiences from Copenhagen with paediatric single photon emission computed tomography/computed tomography. Nucl Med Commun. 32(5):356-62, 2011 May. Review/Other-Dx Fifteen children (eight girls) To evaluate the diagnostic value of single photon emission computed tomographic (SPECT)/multislice computed tomographic (MSCT) fusion images compared with planar scintigraphy in children. Fourteen of the 15 planar scans gained additional structural information from SPECT/CT. Twelve of 15 planar scans gained additional nuclear medicine information. Six studies gained specific information for biopsy guidance. 4
58. DiPoce J, Jbara ME, Brenner AI. Pediatric osteomyelitis: a scintigraphic case-based review. Radiographics 2012;32:865-78. Review/Other-Dx N/A To optimize bone scintigraphy for evaluation of the spectrum of abnormalities associated with pediatric osteomyelitis, with an emphasis on the approaches to patient preparation and positioning and to interpretation. Bone scintigraphy is especially useful when the site of osteomyelitis is unclear. Other imaging modalities, including radiography, ultrasonography, and magnetic resonance imaging, all have advantages and may have a role in evaluating the condition of the child with osteomyelitis. Pathophysiologic considerations unique to children contribute to a different clinical presentation of osteomyelitis in the pediatric population than that seen in adults. In addition, patient movement degrades image quality substantially, which is an important consideration for imaging children. Neonates have a higher incidence of multifocal osteomyelitis, and they represent a unique subset of the pediatric population with separate considerations. 4
59. Tuson CE, Hoffman EB, Mann MD. Isotope bone scanning for acute osteomyelitis and septic arthritis in children. Journal of Bone &#38; Joint Surgery - British Volume. 76(2):306-10, 1994 Mar. Review/Other-Dx 86 children No abstract available. No abstract available. 4
60. Treves S, Khettry J, Broker FH, Wilkinson RH, Watts H. Osteomyelitis: early scintigraphic detection in children. Pediatrics 1976;57:173-86. Review/Other-Dx 9 patients To emphasize the use of bone scintigraphy in the early detection of and localization of osteomyelitis in children. The diagnosis of osteomyelitis was made in seven patients; one patient had a subperiosteal abscess surrounded by osteomyelitis, and one patient had cellulitis. The seven children with osteomyelitis had focal increase of radiopharmaceutical uptake in the bone. The child with the subperiosteal abscess had an area of decreased uptake in the center of the abscess surrounded by a zone of increased uptake of the radioactive bone-seeker. The patient with cellulitis had soft tissue changes by X-ray and a normal bone scintigram. In the seven patients with osteomyelitis, the bone scintigram was performed during the early phase of the disease and no bony changes were present on the roentgenogram. In one patient with subacute osteomyelitis, soft tissue changes were seen radiologically. Only three of the seven children with osteomyelitis developed radiological bony changes. 4
61. Connolly LP, Connolly SA, Drubach LA, Jaramillo D, Treves ST. Acute hematogenous osteomyelitis of children: assessment of skeletal scintigraphy-based diagnosis in the era of MRI. J Nucl Med. 2002; 43(10):1310-1316. Observational-Dx 213 children Retrospective study to assess how effective skeletal scintigraphy is by looking at how often MRI is requested after skeletal scintigraphy, how often diagnoses made with skeletal scintigraphy are changed after MRI, and how often the ability of MRI to show an abscess affects management of acute hematogenous osteomyelitis. Diagnosis was made using skeletal scintigraphy without referral for MRI in 179 (84%) of the children, including 79 (92%) of 86 with a final diagnosis of acute hematogenous osteomyelitis. Treatment and diagnosis were accomplished without referral for MRI in 146 (69%) of all cases and 46 (53%) of the acute hematogenous osteomyelitis cases. Abscesses that required drainage were found in 3 (6%) of 48 cases of major-long-bone acute hematogenous osteomyelitis. Each of these 3 had exhibited a slow therapeutic response before MRI. Drainable abscesses were found in 5 (20%) of 25 cases affecting the pelvis, which was the other preponderant location of acute hematogenous osteomyelitis. These were found with pelvic foci both when MRI was performed at diagnosis and when MRI was performed during treatment. An imaging strategy in which skeletal scintigraphy is the first test used when acute hematogenous osteomyelitis is suspected but radiographs are negative remains highly effective. MRI should be performed after skeletal scintigraphy shows major-long-bone acute hematogenous osteomyelitis if treatment response is slow. Skeletal scintigraphy is also an appropriate first test for suspected radiographically occult pelvic acute hematogenous osteomyelitis. 4
62. Majd M, Frankel RS. Radionclide imaging in skeletal inflammatory and ischemic disease in children. AJR Am J Roentgenol 1976;126:832-41. Review/Other-Dx 65 children To evaluate radionclide imaging in skeletal inflammatory and ischemic disease in children. Several characteristic scintigraphic patterns were observed. Bone scans were significantly more sensitive than roentgenograms in early diagnosis of osteomyelitis and its differentiation from cellulitis, septic arthritis, and bone infarction. 4
63. Linke R, Kuwert T, Uder M, Forst R, Wuest W. Skeletal SPECT/CT of the peripheral extremities. AJR Am J Roentgenol. 194(4):W329-35, 2010 Apr. Observational-Dx 71 patients The aim of this study was to investigate the incremental diagnostic value of skeletal SPECT/CT in the evaluation of pain of the extremities compared with the value of SPECT alone. Four patients had no abnormal bone metabolism or CT abnormality in the extremities. Among 34 lesions classified as osteoarthritis on planar and SPECT images, seven were reclassified as fracture and one as benign tumor at SPECT/CT. Of 15 lesions initially classified as osteomyelitis, four were diagnosed as osteoarthritis, four as fracture, and one as inflammation of the soft tissue only. Of eight diagnoses of fracture with the conventional approach, two were reclassified as osteomyelitis and two as osteoarthritis. In one of 10 patients with the initial diagnosis of a tumorlike lesion, the diagnosis was changed to trauma on the basis of SPECT/CT findings, and in another patient, the diagnosis was changed to osteoarthritis. Overall, SPECT/CT findings led to revision of the diagnostic category in the cases of 23 of 71 patients (p < 0.01). 3
64. Liberman B, Herman A, Schindler A, Sherr-Lurie N, Ganel A, Givon U. The value of hip aspiration in pediatric transient synovitis. Journal of Pediatric Orthopedics. 33(2):124-7, 2013 Mar. Observational-Tx 231 children The aim of this study was to evaluate the use of a single ultrasound-guided hip aspiration as a treatment modality for transient synovitis (TS). Twenty-four hours after admission, limping was noted in 92% and 10% of the patients in groups 1 and 2, respectively, (P < 0.001). Refusal to bear weight was observed in 14% and 1% in groups 1 and 2, respectively, (P < 0.001), and hip joint pain was reported in 81% and 6% in groups 1 and 2, respectively, (P < 0.001). Larger joint effusions were found to be the reason behind the inability to bear weight. 2
65. Kotlarsky P, Shavit I, Kassis I, Eidelman M. Treatment of septic hip in a pediatric ED: a retrospective case series analysis. Am J Emerg Med. 34(3):602-5, 2016 Mar. Observational-Dx 235 patients To discuss the best protocol for planar image acquisition and interpretation of radiolabelled white blood cell (WBC) scintigraphy. Between January 1, 2007, and December 31, 2014, 17 children with septic hip were diagnosed by emergency physicians using point-of-care ultrasonography. All were treated with AHED. During hospital admission, a median of 2 (interquartile range [IQR], 2-3) follow-up sonographic examinations per patient was performed; 10 (59%) patients did not have another hip aspiration, and 7 (41%) had a median of 1 (IQR, 1-3) hip joint aspiration under sedation. Median length of antibiotic treatment was 28 days (IQR, 21-40). No patient underwent arthrotomy, and all recovered without disability in up to 4 years of follow-up. 3
66. Schlung JE, Bastrom TP, Roocroft JH, Newton PO, Mubarak SJ, Upasani VV. Femoral Neck Aspiration Aids in the Diagnosis of Osteomyelitis In Children With Septic Hip. J Pediatr Orthop. 38(10):532-536, 2018 Nov/Dec. Observational-Dx 83 patients To determine if femoral aspiration (FA) conducted concomitantly with irrigation and debridement (I&D) of the septic hip aids in microorganism and osteomyelitis identification and alters the treatment plan, or if the risks of the procedure outweigh its potential benefit. Among the 83 patients with confirmed or suspected septic arthritis, 31 patients (37%) had a FA performed at the time of the hip I&D, resulting in positive cultures in 17 patients. All of these patients had other positive cultures (blood and/or joint fluid) that grew the same organism. 54 patients (65%) had a preoperative MRI. The MRI was falsely negative in 10 patients, 6 of whom had a positive FA resulting in appropriate management of osteomyelitis. Missed or delayed diagnosis of osteomyelitis resulted in significant morbidity in 3 patients (avascular necrosis and femoral neck fracture, extensive lower extremity osteomyelitis, and subtrochanteric fracture with malunion). No complications associated with FA were identified. FA and MRI were found to have sensitivity/specificity for osteomyelitis of 100%/100% and 38%/95%, respectively. 3
67. Courtney PM, Flynn JM, Jaramillo D, Horn BD, Calabro K, Spiegel DA. Clinical indications for repeat MRI in children with acute hematogenous osteomyelitis. J Pediatr Orthop. 30(8):883-7, 2010 Dec. Observational-Dx 59 children To examine several clinical indications for ordering a repeat magnetic resonance imaging (MRI) and whether the imaging study resulted in a change in management. The median age of our patient population was 8.4 years; a total of 104 repeat MRI studies were undertaken on 59 children. Eleven (10.6%) of these studies prompted a change in patient treatment. Statistically significant indications for repeat MRI in changing clinical management included failure to improve clinically in 10 studies (21%, P<0.001), persistently elevated or increasing CRP levels in 11 MRI studies (52%, P<0.001), and the repeat study occurring within 14 days of the diagnostic MRI in 8 studies (29%, P=0.003). 3
68. Montgomery CO, Siegel E, Blasier RD, Suva LJ. Concurrent septic arthritis and osteomyelitis in children. Journal of Pediatric Orthopedics. 33(4):464-7, 2013 Jun. Review/Other-Dx 200 patients To identify factors that may help to diagnosis concurrent infections (CI) earlier. Two hundred patients were eligible and analyzed, of which 43 (21.5%) had CI. On the basis of age, CI were most common in newborns and adolescents (P<0.0001). On the basis of location, 72% of shoulder infections (P<0.0001) were concurrent, whereas <50% of elbows, hips, knees, and ankle were CI. The most common infective organism was methicillin-sensitive Staphylococcus aureus (P<0.0001). CI were significantly associated with increased median (6) days of clinical symptoms before presentation (P<0.0001), increased duration of median (6) days of hospital stay (P<0.0001), increased number of operative procedures (P=0.005), and increased need for ICU admission (P=0.024). 4
69. Welling BD, Haruno LS, Rosenfeld SB. Validating an Algorithm to Predict Adjacent Musculoskeletal Infections in Pediatric Patients With Septic Arthritis. Clin Orthop. 476(1):153-159, 2018 01. Observational-Dx 57 patients To test and evaluate the predictive power of the algorithm on a new patient population. In the new population, the sensitivity and specificity of the algorithm were 86% (95% CI, 0.70-0.95) and 85% (95% CI, 0.64-0.97), respectively. The positive predictive value was determined to be 91% (95% CI, 0.78-0.97), with a negative predictive value of 77% (95% CI, 0.61-0.89). All patients meeting four or more algorithm criteria were found to have septic arthritis with adjacent infection on MRI. 3
70. 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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