| 1. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services; 2021. Available at: https://www.cdc.gov/diabetes/php/data-research/?CDC_AAref_Val=https://www.cdc.gov/diabetes/data/statistics-report/index.html. |
Review/Other-Dx |
NA |
No abstract available. |
No abstract available. |
4 |
| 2. Duryea D, Bernard S, Flemming D, Walker E, French C. Outcomes in diabetic foot ulcer patients with isolated T2 marrow signal abnormality in the underlying bone: should the diagnosis of "osteitis" be changed to "early osteomyelitis"?. Skeletal Radiol. 46(10):1327-1333, 2017 Oct. |
Observational-Dx |
28 patients |
To evaluate the variability of clinical treatment and outcomes based on reporting of diabetic foot ulcer mgnetic resonance imaging (MRI) findings of adjacent marrow T2 hyperintensity with normal T1 signal. |
The isolated marrow T2 signal hyperintensity was reported as "osteitis without osteomyelitis" (OW) in 12 patients, osteitis but cannot exclude early osteomyelitis" (OCEO) in 18, and "early osteomyelitis" (EO) in 16. No statistical difference in clinical assessment was demonstrated between the OW, OCEO, and EO groups. Pathological condition was available in 15 patients within 0-7 days (mean 2.4 days) of the MRI examination, with 14 (93%) of these positive for osteomyelitis by histopathology or positive cultures. Initial diagnosis of or progression to osteomyelitis was shown in 28 patients (61%). |
3 |
| 3. Palestro C, Clark A, Grady E, et al. Appropriate Use Criteria for the Use of Nuclear Medicine in Musculoskeletal Infection Imaging. Journal of Nuclear Medicine. 2021 Sep 30. |
Review/Other-Dx |
NA |
No abstract available. |
No abstract available. |
4 |
| 4. Butalia S, Palda VA, Sargeant RJ, Detsky AS, Mourad O. Does this patient with diabetes have osteomyelitis of the lower extremity? JAMA. 2008; 299(7):806-813. |
Review/Other-Dx |
21articles reviewed |
To determine the accuracy of historical features, physical examination, and laboratory and basic radiographic testing. We searched for systematic reviews of MRI in the diagnosis of lower extremity osteomyelitis in patients with diabetes to compare its performance with the reference standard. |
The gold standard for diagnosis is bone biopsy. An ulcer area larger than 2 cm2 (positive LR, 7.2; 95% CI, 1.1-49; negative LR, 0.48; 95% CI, 0.31-0.76) and a positive “probe-to-bone” test result (summary positive LR, 6.4; 95% CI, 3.6-11; negative LR, 0.39; 95% CI, 0.20-0.76) were the best clinical findings. An erythrocyte sedimentation rate of more than 70 mm/h increases the probability of a diagnosis of osteomyelitis (summary LR, 11; 95% CI, 1.6-79). An abnormal radiograph doubles the odds of osteomyelitis (summary LR, 2.3; 95% CI, 1.6-3.3). A positive MRI result increases the likelihood of osteomyelitis (summary LR, 3.8; 95% CI, 2.5-5.8). However, a normal MRI result makes osteomyelitis much less likely (summary LR, 0.14; 95% CI, 0.08-0.26). The overall accuracy (ie, the weighted average of the sensitivity and specificity) of the MRI is 89% (95% CI, 83.0%-94.5%). An ulcer area larger than 2 cm2, a positive probe-to-bone test result, an erythrocyte sedimentation rate of more than 70 mm/h, and an abnormal radiograph result are helpful in diagnosing the presence of lower extremity osteomyelitis in patients with diabetes. A negative MRI result makes the diagnosis much less likely when all of these findings are absent. No single historical feature or physical examination reliably excludes osteomyelitis. The diagnostic utility of a combination of findings is unknown. |
4 |
| 5. Markanday A.. Diagnosing diabetic foot osteomyelitis: narrative review and a suggested 2-step score-based diagnostic pathway for clinicians. [Review]. Open forum infect. dis.. 1(2):ofu060, 2014 Sep. |
Review/Other-Dx |
N/A |
To review the Diagnosing diabetic foot osteomyelitis. |
No results stated in abstract. |
4 |
| 6. Dinh MT, Abad CL, Safdar N. Diagnostic accuracy of the physical examination and imaging tests for osteomyelitis underlying diabetic foot ulcers: meta-analysis. Clin Infect Dis. 2008; 47(4):519-527. |
Meta-analysis |
68 total studies; 9 studies from literature search including 59 additional studies found from references |
To critically evaluate the diagnostic accuracy of clinical examination, radiographs, bone scan, WBC scan and MRI for diagnosis of osteomyelitis in diabetic patients with foot ulcers. |
Exposed bone or probe-to-bone test had a sensitivity of 0.60 and a specificity of 0.91. Radiography had a sensitivity of 0.54 and a specificity of 0.68. MRI had a sensitivity of 0.90 and a specificity of 0.79. Bone scan was found to have a sensitivity of 0.81 and a specificity of 0.28. Leukocyte scan was found to have a sensitivity of 0.74 and a specificity of 0.68. The diagnostic odds ratios for clinical examination, radiography, MRI, bone scan, and leukocyte scan were 49.45, 2.84, 24.36, 2.10, and 10.07, respectively. Radiography: 54% sensitive, 68% specific. MRI: 90% sensitive, 79% specific. Tc-MDP: 81% sensitive, 28% specific. In-WBC: 74% sensitive, 68% specific. The presence of exposed bone or a positive probe-to-bone test result is moderately predictive of osteomyelitis. MRI is the most accurate imaging test for diagnosis of osteomyelitis. |
M |
| 7. Senneville E, Albalawi Z, van Asten SA, et al. IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes-related foot infections (IWGDF/IDSA 2023). [Review]. Diabetes/Metabolism Research Reviews. e3687, 2023 Oct 01. |
Review/Other-Dx |
NA |
No abstract available. |
No abstract available. |
4 |
| 8. Malone M, Bowling FL, Gannass A, Jude EB, Boulton AJ. Deep wound cultures correlate well with bone biopsy culture in diabetic foot osteomyelitis. Diabetes Metab Res Rev. 29(7):546-50, 2013 Oct. |
Observational-Dx |
66 cases |
To determine if pathogen/s isolated via deep wound swabs correlated with bone biopsy isolates. |
Of 66 cases of suspected osteomyelitis in 102 joints, 34 patients had both bone biopsies and deep wound cultures over the study period. Thirty two of 34 (94%), had a history of preceding foot ulceration, and in 25 of the cases a positive probe to bone test was recorded. In a high proportion of patients, at least one similar organism was isolated from both the deep wound culture and bone biopsy procedures (25 of 34 cases, 73.5%, p<0.001). When organisms were isolated from both wound cultures and bone biopsies, the identical strain was identified in both procedures in a significant proportion of cases (16 of 25 cases, 64%, p<0.001, total sample analysis in 16 of 34 cases, 47%) |
3 |
| 9. Pierce JL, Perry MT, Wessell DE, et al. ACR Appropriateness Criteria® Suspected Osteomyelitis, Septic Arthritis, or Soft Tissue Infection (Excluding Spine and Diabetic Foot): 2022 Update. J Am Coll Radiol 2022;19:S473-S87. |
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 suspected osteomyelitis, septic arthritis, or soft tissue infection (excluding spine and diabetic foot). |
No results stated in abstract. |
4 |
| 10. Tafur M, Bencardino JT, Roberts CC, et al. ACR Appropriateness Criteria® Chronic Foot Pain. J Am Coll Radiol 2020;17:S391-S402. |
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 |
No results stated in abstract. |
4 |
| 11. Chang EY, Tadros AS, Amini B, et al. ACR Appropriateness Criteria® Chronic Ankle Pain. J Am Coll Radiol 2018;15:S26-S38. |
Review/Other-Dx |
NA |
Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for Chronic Ankle Pain. |
No results stated in abstract. |
4 |
| 12. Gorbachova T, Chang EY, Ha AS, et al. ACR Appropriateness Criteria® Acute Trauma to the Foot. J Am Coll Radiol 2020;17:S2-S11. |
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 |
No results stated in abstract. |
4 |
| 13. Smith SE, Chang EY, Ha AS, et al. ACR Appropriateness Criteria® Acute Trauma to the Ankle. J Am Coll Radiol 2020;17:S355-S66. |
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 acute trauma to the ankle. |
No results stated in abstract. |
4 |
| 14. Mens MA, de Geus A, Wellenberg RHH, et al. Preliminary evaluation of dual-energy CT to quantitatively assess bone marrow edema in patients with diabetic foot ulcers and suspected osteomyelitis. Eur Radiol. 33(8):5645-5652, 2023 Aug. |
Observational-Dx |
56 foot ulcers |
The purpose of this study is to evaluate the value of dual-energy CT (DECT) with virtual non-calcium (VNCa) in quantitatively assessing the presence of bone marrow edema (BME) in patients with diabetic foot ulcers and suspected osteomyelitis. |
A total of 56 foot ulcers were identified of which 23 were included in the osteomyelitis group. The mean CT value at the ulcer location was significantly higher in the osteomyelitis group (- 17.23 ± 34.96 HU) compared to the no-osteomyelitis group (- 69.34 ± 49.40 HU; p < 0.001). Within the osteomyelitis group, the difference between affected bone and reference bone was statistically significant (p < 0.001), which was not the case in the group without osteomyelitis (p = 0.052). The observer agreement was good for affected bone measurements (ICC = 0.858) and moderate for reference bone measurements (ICC = 0.675). With a cut-off value of - 40.1 HU, sensitivity was 87.0%, specificity was 72.7%, PPV was 69.0%, and NPV was 88.9%. |
2 |
| 15. Heidari N, Oh I, Li Y, et al. What Is the Best Method to Differentiate Acute Charcot Foot From Acute Infection?. Foot & Ankle International. 40(1_suppl):39S-42S, 2019 Jul. |
Review/Other-Dx |
NA |
No abstract available. |
No abstract available. |
4 |
| 16. Llewellyn A, Kraft J, Holton C, Harden M, Simmonds M. Imaging for detection of osteomyelitis in people with diabetic foot ulcers: A systematic review and meta-analysis. European Journal of Radiology. 131:109215, 2020 Oct. |
Meta-analysis |
32 studies |
To review the evidence on the diagnostic accuracy of imaging tests to diagnose osteomyelitis in people with diabetic foot ulcers. |
Thirty-six studies were included in the meta-analysis. Eight studies were at high risk of bias MRI had high diagnostic accuracy (22 studies: 96.4 % sensitivity (95 % CI 90.7-98.7); 83.8 % specificity (76.0-89.5)). PET scans also had high accuracy (6 studies: 84.3 % sensitivity (52.8-96.3); 92.8 % specificity (75.7-98.2)), and possibly also SPECT, but with few studies (3 studies: 95.6 % sensitivity (76.0-99.3); 55.1 % specificity (19.3-86.3)). Scintigraphy (17 studies: 84.2 % sensitivity (76.8-89.6); 67.7 % specificity (56.2-77.4)), and X-rays (16 studies: 61.9 % sensitivity (50.5-72.1); 78.3 % specificity (62.9-88.5)) had generally inferior diagnostic accuracy. |
Good |
| 17. 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 |
| 18. Harmer JL, Pickard J, Stinchcombe SJ. The role of diagnostic imaging in the evaluation of suspected osteomyelitis in the foot: a critical review. [Review]. FOOT. 21(3):149-53, 2011 Sep. |
Review/Other-Dx |
N/A |
To review the advantages and disadvantages of the main imaging techniques used for the evaluation of the foot when osteomyelitis is suspected. |
An evidence based algorithm for the selection of appropriate imaging techniques is suggested to aid clinicians in their decision making process. |
4 |
| 19. Pineda C, Espinosa R, Pena A. Radiographic imaging in osteomyelitis: the role of plain radiography, computed tomography, ultrasonography, magnetic resonance imaging, and scintigraphy. Seminars in plastic surgery 2009;23:80-9. |
Review/Other-Dx |
N/A |
To review the role of plain radiography, computed tomography, ultrasonography, magnetic resonance imaging, and scintigraphy in osteomyelitis. |
No results listed in abstract. |
4 |
| 20. Palestro CJ, Mehta HH, Patel M, et al. Marrow versus infection in the Charcot joint: indium-111 leukocyte and technetium-99m sulfur colloid scintigraphy. Journal of Nuclear Medicine. 39(2):346-50, 1998 Feb. |
Observational-Dx |
17 patients |
To evaluate the role of combined leukocyte/marrow scintigraphy in the assessment of the neuropathic or Charcot joint. |
Labeled leukocyte accumulation in the uninfected Charcot joint does occur and is related, at least in part, to hematopoietically active marrow. Leukocyte/marrow scintigraphy is a reliable way to differentiate between marrow and infection as the cause of labeled leukocyte accumulation in the neuropathic joint and, in this series, was superior to both three-phase bone scintigraphy and combined leukocyte/bone scintigraphy. |
3 |
| 21. 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 |
| 22. Heiba SI, Kolker D, Mocherla B, et al. The optimized evaluation of diabetic foot infection by dual isotope SPECT/CT imaging protocol. J Foot Ankle Surg. 49(6):529-36, 2010 Nov-Dec. |
Observational-Dx |
272 patients |
To investigate a method that combines the imaging of multiple radiopharmaceuticals using single-photon emission computedtomography/computed tomography (SPECT/CT) fusion for an accurate diagnosis and precise localization of diabetic foot infection. |
Distinction between various diagnostic categories and overall osteomyelitis (OM) diagnostic accuracy in 213 patients were higher for DI than WBCS or bone scintigraphy (BS) alone, and for DI SPECT/CT than DI planar or SPECT only. Diagnostic confidence/lesion site was significantly higher for DI SPECT/CT than other comparative imaging methods. In a group of 97 patients with confirmed microbiologic/pathologic diagnosis, similar results were attained. Step 2 DI SPECT/CT performed in 67 patients further improved diagnostic accuracy/confidence. DI SPECT/CT is a highly accurate modality that considerably improves detection and discrimination of STI and OM while providing precise anatomic localization in the diabetic foot. This combined imaging technique promises to beneficially impact diabetic patient care. |
2 |
| 23. 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 |
| 24. Palestro CJ, Roumanas P, Swyer AJ, Kim CK, Goldsmith SJ. Diagnosis of musculoskeletal infection using combined In-111 labeled leukocyte and Tc-99m SC marrow imaging. Clin Nucl Med 1992;17:269-73. |
Observational-Dx |
73 patients |
The objective of this retrospective review was to evaluate the utility of leukocyte imaging both alone and in combination with Tc99m sulfur colloid marrow imaging for the diagnosis of musculoskeletal infection in patients with underlying, potentially marrow-altering, conditions. |
There were 22 cases of infection among the 73 patients studied. When interpreted in isolation, labeled leukocyte images were considered positive for infection when uptake of labeled cells in the region of interest exceeded uptake in the corresponding contralateral side. The sensitivity, specificity, and accuracy of the study using this criterion were 86%, 12%, and 34%, respectively. When interpreted in conjunction with sulfur colloid marrow images, studies were considered positive for infection when uptake in the region of interest on leukocyte and marrow images was spatially incongruent. The sensitivity, specificity, and accuracy of this dual tracer modality were 100%, 94%, and 96%, respectively. Three patients with infection and abnormal leukocyte/marrow images underwent repeat imaging after appropriate therapy. Images were interpreted as normal in two of them; both were infection free at subsequent surgery. Images of the third patient were interpreted as consistent with persistent infection, and operative cultures grew out Staphylococcus aureus. |
3 |
| 25. Schauwecker DS, Park HM, Burt RW, Mock BH, Wellman HN. Combined bone scintigraphy and indium-111 leukocyte scans in neuropathic foot disease. J Nucl Med. 29(10):1651-5, 1988 Oct. |
Observational-Dx |
18 patients |
To detect and to accurately localize infection to bone and/or to the adjacent soft tissues of the feet. |
Among the 18 patients without osteomyelitis, eight had no accumulation of [111In]leukocytes, seven had the [111In]leukocyte activity correctly localized to the soft tissue, two had [111In]leukocyte activity mistakenly attributed to the bone, and one had [111In]leukocyte accumulation in a proven neuroma which was mistakenly attributed to bone. These three false-positive results for osteomyelitis reduced the specificity to 83%. Considering only the 27 patients with a positive [111In]leukocyte study, the combined bone scan and [111In]leukocyte study correctly localized the infection to the soft tissues or bone in 89%. |
3 |
| 26. Seabold JE, Flickinger FW, Kao SC, et al. Indium-111-leukocyte/technetium-99m-MDP bone and magnetic resonance imaging: difficulty of diagnosing osteomyelitis in patients with neuropathic osteoarthropathy. J Nucl Med. 31(5):549-56, 1990 May. |
Observational-Dx |
14 patients |
To evaluate the accuracy of these techniques in the detection of osteomyeitis. |
Five of 16 sites (31%) had false-positive 111In-WBC uptake at noninfected sites. There were four true-positive and three false-positive MR studies. All false-positives showed at least moderately abnormal findings by both techniques at sites of rapidly progressing osteoarthropathy of recent onset. In this preliminary study, both techniques appear to be sensitive for detection of osteomyelitis, and a negative study makes osteomyelitis unlikely. However, the findings of 111In-WBC/99mTc-MDP and MR images at sites of rapidly progressing, noninfected neuropathic osteoarthropathy may be indistinguishable from those of osteomyelitis. |
3 |
| 27. Devillers A, Moisan A, Hennion F, Garin E, Poirier JY, Bourguet P. Contribution of technetium-99m hexamethylpropylene amine oxime labelled leucocyte scintigraphy to the diagnosis of diabetic foot infection. Eur J Nucl Med. 25(2):132-8, 1998 Feb. |
Observational-Dx |
42 patients |
We conducted a prospective study in order to evaluate the contribution of technetium-99m hexamethylpropylene amine oxime (HMPAO) labelled leucocyte scintigraphy to the diagnosis and follow-up of osteomyelitis in the diabetic foot. |
The initial exploration included standard radiography, three-phase bone scintigraphy and 99mTc-HMPAO labelled leucocyte scintigraphy (HMPAO-LS), performed within a 3-day interval. For the 56 ulceration sites, 26 cases of osteomyelitis were diagnosed: ten on the basis of radiographic and histological/bacteriological criteria after bone biopsy, 11 after radiographic follow-up and five on the basis of biopsy results alone. No osteomyelitis was present at 30 sites, there were seven cases of cellulitis. The sensitivity and specificity of 99mTc-HMPAO-LS were 88.4% and 96.6% respectively (23 true-positives, 29 true-negatives, one false-positive, three false-negatives). The accuracy of radiography, 99mTc-methylene diphosphonate and HMPAO-LS was 69.6%, 62.5%, and 92.9%, respectively. Follow-up scintigraphy (n = 14) 4 months after initial diagnosis and 1 month after antibiotic withdrawal confirmed cure of osteomyelitis despite the absence of complete clinical regression of the ulcers. In conclusion, 99mTc-HMPAO labelled leucocyte scintigraphy was found to be an excellent method for the diagnosis of osteomyelitis in the diabetic foot. It can contribute to follow-up, particularly when clinical regression of perforating ulcers is incomplete and cure of osteomyelitis must be confirmed in order that antibiotic treatment may be discontinued. |
2 |
| 28. Johnson JE, Kennedy EJ, Shereff MJ, Patel NC, Collier BD. Prospective study of bone, indium-111-labeled white blood cell, and gallium-67 scanning for the evaluation of osteomyelitis in the diabetic foot. Foot Ankle Int 1996;17:10-6. |
Observational-Dx |
22 adults |
Twenty-two adult diabetic patients with clinical suspicion of foot and/or ankle infection were prospectively evaluated using radiography, technetium-99m methylene diphosphonate bone scanning (99Tc), indium-111-labeled leukocyte scanning (111In), and gallium-67 scanning (67Ga) to determine the presence of clinically suspected osteomyelitis. |
Biopsy for culture and histology was performed in 16 patients. The diagnosis of osteomyelitis was confirmed by biopsy in 12 patients. The remaining 10 patients had no evidence of osteomyelitis with long-term follow-up. 99mTc was snown to be of limited valued when used alone in these patients with peripheral neuropathy. 67Ga, either alone or in combination with 99mTc bone scanning, was of little diagnostic value and gave no additional information that was not available from 111In.The combination of three-phase 99mTc and 111In had the highest diagnostic efficacy (100% sensitivity, 80% specificity, and 91% accuracy), followed closely by 111In alone (100% sensitivity, 70% specificity, and 86% accuracy). |
3 |
| 29. Termaat MF, Raijmakers PG, Scholten HJ, Bakker FC, Patka P, Haarman HJ. The accuracy of diagnostic imaging for the assessment of chronic osteomyelitis: a systematic review and meta-analysis. J Bone Joint Surg Am. 2005; 87(11):2464-2471. |
Meta-analysis |
23 studies |
Systematic review and meta-analysis was performed to determine the accuracy of current imaging modalities in the diagnosis of chronic osteomyelitis. The value of each imaging technique was studied by determining its sensitivity and specificity compared with the results of histological analysis, findings on culture, and clinical follow-up of more than six months. |
Pooled sensitivity demonstrated that FDG-PET was the most sensitive technique, with a sensitivity of 96% (95% CI, 88%-99%) Pooled specificity demonstrated that bone scintigraphy had the lowest specificity, with a specificity of 25% (95% CI, 16%-36%) FDG-PET has the highest diagnostic accuracy for confirming or excluding the diagnosis of chronic osteomyelitis. Leukocyte scintigraphy has an appropriate diagnostic accuracy in the peripheral skeleton, but FDG-PET is superior for detecting chronic osteomyelitis in the axial skeleton. |
Inadequate |
| 30. Filippi L, Schillaci O. Usefulness of hybrid SPECT/CT in 99mTc-HMPAO-labeled leukocyte scintigraphy for bone and joint infections. J Nucl Med. 2006;47(12):1908-1913. |
Observational-Dx |
28 patients |
To evaluate the usefulness of SPECT and transmission CT performed simultaneously using a hybrid imaging device for the functional anatomic mapping of bone and joint infections. |
(99m)Tc-HMPAO scintigraphy was true-positive for infection in 18/28 patients (for a total of 21 sites of uptake) and true-negative in 10/28 subjects. SPECT/CT provided an accurate anatomic localization of all positive foci. With regard to the final diagnosis, SPECT/CT added a significant clinical contribution in 10/28 patients (35.7%). In fact, SPECT/CT differentiated soft-tissue from bone involvement both in patients with osteomyelitis and in patients with orthopedic implants, allowed correct diagnosis of osteomyelitis in patients with structural alterations after trauma, and identified synovial infection without prosthesis involvement in patients with a knee implant. |
2 |
| 31. Horger M, Eschmann SM, Pfannenberg C, et al. The value of SPET/CT in chronic osteomyelitis. Eur J Nucl Med Mol Imaging. 2003;30(12):1665-1673. |
Observational-Dx |
27 patients |
To evaluate the use of a combined SPECT/CT device to improve detection and anatomical definition of inflammatory bone lesions. |
On a lesion-by-lesion basis 19 true positive, 1 false positive and 9 true negative findings were obtained. SPECT/CT correctly identified the location of all positive foci in the appendicular skeleton and that of a cold lesion in the axial skeleton. It also enabled differentiation between soft tissue infection, septic arthritis and osteomyelitis, as well as between cortical, corticomedullary and subperiosteal foci. Sensitivity was identical for SPECT and SPECT/CT (100%), whereas specificity was improved from 78% to 89% by the use of SPECT/CT. Combined SPECT/CT improves the accuracy of immunoscintigraphy by allowing correct differentiation between soft tissue infection and bone involvement. |
3 |
| 32. 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 |
| 33. La Fontaine J, Bhavan K, Lam K, et al. Comparison Between Tc-99m WBC SPECT/CT and MRI for the Diagnosis of Biopsy-proven Diabetic Foot Osteomyelitis. WOUNDS. 28(8):271-8, 2016 Aug. |
Observational-Dx |
110 patients |
To diagnose osteomyelitis is bone biopsy, with a positive culture and/or histopathology findings consistent with osteomyelitis. |
For inclusion criteria, 110 patients met the study's criteria: 52 single-photon emission computed tomography/computed tomography (SPECT/CT) patients and 58 Magnetic resonance imaging (MRI) patients. The sensitivity, specificity, positive predictive value, and negative predictive value of SPECT/CT were 89%, 35%, 74%, and 60%, respectively; the corresponding values for MRI were 87%, 37%, 74%, and 58%, respectively. There were no significant differences in accuracy of diagnosing diabetic foot osteomyelitis (DFO) between imaging techniques. |
3 |
| 34. Larcos G, Brown ML, Sutton RT. Diagnosis of osteomyelitis of the foot in diabetic patients: value of 111In-leukocyte scintigraphy. AJR 1991;157:527-31. |
Observational-Dx |
51 adults |
To diagnose osteomyelitis of the foot in diabetic patients with 111In-leukocyte scintigraphy. |
Accordingly, we retrospectively reviewed 51 111In-labeled leukocyte scans, 49 technetium-99m bone scans, and 49 plain radiographs obtained in 51 adults with diabetes in whom osteomyelitis of the foot was suspected. The sensitivity and specificity of these techniques were evaluated in all patients, as well as in a subgroup of 11 patients with neuroarthropathy. Results with 111In-labeled leukocyte scans were also examined in subsets of patients with soft-tissue ulcers (n = 35) and those receiving antibiotics during investigation (n = 20). Confirmation or exclusion of osteomyelitis was made surgically in 28 patients and clinically in 23. Fourteen patients had osteomyelitis. Bone scans were most sensitive (93%) but least specific (43%); plain radiographs were most specific (83%) but least sensitive (43%). 111In-labeled leukocyte scans were both sensitive (79%) and specific (78%), and remained useful in patients with neuroarthropathy, soft-tissue ulcers, and antibiotic treatment. Poor spatial resolution contributed to the false-negative and false-positive 111In-labeled leukocyte scans, suggesting that this technique should not be interpreted independent of other tests. 111In-labeled leukocyte scans are a valuable diagnostic tool for the diagnosis of pedal osteomyelitis in diabetic patients. |
3 |
| 35. Schauwecker DS. The scintigraphic diagnosis of osteomyelitis. AJR 1992;158:9-18. |
Review/Other-Dx |
NA |
This article reviews the current scintigraphic procedures used in the diagnosis of osteomyelitis and discusses some of the newer radiopharmaceuticals now being developed. The goal is to understand the strengths and weaknesses of each method so that the procedure most effective for specific clinical settings can be selected. |
No results listed in abstract. |
4 |
| 36. Yuh WT, Corson JD, Baraniewski HM, et al. Osteomyelitis of the foot in diabetic patients: evaluation with plain film, 99mTc-MDP bone scintigraphy, and MR imaging. AJR 1989;152:795-800. |
Observational-Dx |
24 patients |
This study compared the diagnostic accuracies of plain films, bone scans, and MR imaging studies in diabetic patients with suspicion of osteomyelitis of the foot. |
The sensitivity and specificity of plain films were both 75%. Bone scans had a very low specificity (100% false-positive rate). A negative bone scan should strongly exclude the probability of osteomyelitis. Unlike the findings in previous reports, MR had much higher sensitivity and specificity than bone scans in detecting osteomyelitis in diabetic patients. When the 10 patients without pathologic proof (those who presumably had neuroarthropathy, vascular insufficiency, and/or cellulitis) were included, the sensitivity and specificity of all three techniques decreased. |
2 |
| 37. Jay PR, Michelson JD, Mizel MS, Magid D, Le T. Efficacy of three-phase bone scans in evaluating diabetic foot ulcers. Foot Ankle Int. 1999; 20(6):347-355. |
Observational-Dx |
34 bone scans |
To retrospectively evaluate the utility of bone scans in determining the treatment of diabetic patients with foot ulcers. |
There was no significant difference in the amputation rate for patients with confirmatory, indeterminate, or nonconfirmatory bone scans for osteomyelitis (36%, 37%, and 50%, respectively) (P>0.5). Therefore, it is concluded that the ultimate treatment should be based on clinical indicators of the presence of uncontrolled infection or gangrene rather than on bone scan findings. |
3 |
| 38. Mandell JC, Khurana B, Smith JT, Czuczman GJ, Ghazikhanian V, Smith SE. Osteomyelitis of the lower extremity: pathophysiology, imaging, and classification, with an emphasis on diabetic foot infection. [Review]. EMERG. RADIOL.. 25(2):175-188, 2018 Apr. |
Review/Other-Dx |
N/A |
To review the pathophysiology, imaging, and classification, with an emphasis on diabetic foot infection. |
No results stated in abstract. |
4 |
| 39. Chantelau EA, Grutzner G. Is the Eichenholtz classification still valid for the diabetic Charcot foot?. [Review]. Swiss Med Wkly. 144:w13948, 2014. |
Review/Other-Dx |
N/A |
To propose an magnetic resonance imaging (MRI)-based classification comprising two severity grades (0 and 1, according to absence/presence of cortical fractures) and two stages (active/inactive, according to presence/absence of skeletal inflammation). |
No results stated in abstract. |
4 |
| 40. Trieb K.. The Charcot foot: pathophysiology, diagnosis and classification. [Review]. Bone Joint J. 98-B(9):1155-9, 2016 Sep. |
Review/Other-Dx |
N/A |
To raise awareness of the diagnosis of the Charcot foot (diabetic neuropathic osteoarthropathy and the differential diagnosis, erysipelas, peripheral arterial occlusive disease) and describe the ways in which the diagnosis may be made. |
No results stated in the abstract. |
4 |
| 41. 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 |
| 42. Kagna O, Srour S, Melamed E, Militianu D, Keidar Z. FDG PET/CT imaging in the diagnosis of osteomyelitis in the diabetic foot. Eur J Nucl Med Mol Imaging. 39(10):1545-50, 2012 Oct. |
Observational-Dx |
39 patients |
To assess the value of Fluorodeoxyglucose F18 (FDG) PET/ computed tomography (CT) in diabetic patients with clinically suspected osteomyelitis. |
Osteomyelitis was correctly diagnosed in 18 and excluded in 21 sites. Of 20 lesions with focal bone FDG uptake, 2 were false-positive with no further evidence of osteomyelitis. Five sites of diffuse FDG uptake involving more than one bone on CT were correctly diagnosed as diabetic osteoarthropathy. FDG PET/CT had a sensitivity, specificity and accuracy of 100 %, 92 % and 95 % in a patient-based analysis and 100 %, 93 % and 96 % in a lesion-based analysis, respectively, for the diagnosis of osteomyelitis in the diabetic foot. |
1 |
| 43. Keidar Z, Militianu D, Melamed E, Bar-Shalom R, Israel O. The diabetic foot: initial experience with 18F-FDG PET/CT. J Nucl Med. 46(3):444-9, 2005 Mar. |
Observational-Dx |
14 diabetic patients |
To assess the role of PET/CT using FDG for the diagnosis of diabetic foot osteomyelitis. |
PET detected 14 foci of increased FDG uptake suspected as infection in 10 patients. PET/CT correctly localized 8 foci in 4 patients to bone, indicating osteomyelitis. PET/CT correctly excluded osteomyelitis in 5 foci in 5 patients, with the abnormal FDG uptake limited to infected soft tissues only. One site of mildly increased focal FDG uptake was localized by PET/CT to diabetic osteoarthropathy changes demonstrated on CT. Four patients showed no abnormally increased FDG uptake and no further evidence of an infectious process on clinical and imaging follow-up. FDG-PET can be used for diagnosis of diabetes-related infection. The precise anatomic localization of increased FDG uptake provided by PET/CT enables accurate differentiation between osteomyelitis and soft-tissue infection. |
3 |
| 44. Lauri C, Tamminga M, Glaudemans AWJM, et al. Detection of Osteomyelitis in the Diabetic Foot by Imaging Techniques: A Systematic Review and Meta-analysis Comparing MRI, White Blood Cell Scintigraphy, and FDG-PET. [Review]. Diabetes Care. 40(8):1111-1120, 2017 08. |
Meta-analysis |
27 articles; 2 posters |
To compare the diagnostic performances of MRI, radiolabeled white blood cell (WBC) scintigraphy (either with (99m)Tc-hexamethylpropyleneamineoxime [HMPAO] or (111)In-oxine), and [(18)F]fluorodeoxyglucose positron emission tomography ((18)F-FDG-PET)/computed tomography. |
Our review found 6,649 articles; 3,894 in Medline and 2,755 in Embase. A total of 27 full articles and 2 posters was selected for inclusion in the analysis. The performance characteristics for the (18)F-FDG-PET were: sensitivity, 89%; specificity, 92%; diagnostic odds ratio (DOR), 95; positive likelihood ratio (LR), 11; and negative LR, 0.11. For WBC scan with (111)In-oxine, the values were: sensitivity, 92%; specificity, 75%; DOR, 34; positive LR, 3.6; and negative LR, 0.1. For WBC scan with (99m)Tc-HMPAO, the values were: sensitivity, 91%; specificity, 92%; DOR, 118; positive LR, 12; and negative LR, 0.1. Finally, for MRI, the values were: sensitivity, 93%; specificity, 75%; DOR, 37; positive LR, 3.66, and negative LR, 0.10 |
Good |
| 45. Treglia G, Sadeghi R, Annunziata S, et al. Diagnostic performance of Fluorine-18-Fluorodeoxyglucose positron emission tomography for the diagnosis of osteomyelitis related to diabetic foot: a systematic review and a meta-analysis. [Review]. FOOT. 23(4):140-8, 2013 Dec. |
Meta-analysis |
9 studies |
To systematically review and meta-analyse published data about the diagnostic performance of Fluorine-18-Fluorodeoxyglucose ((18)F-FDG) positron emission tomography (PET) and PET/computed tomography (PET/CT) in osteomyelitis related to diabetic foot. |
Nine studies comprising 299 patients with diabetic foot were included in the qualitative analysis (systematic review) and discussed. The quantitative analysis (meta-analysis) of four selected studies provided the following results on a per patient-based analysis: sensitivity was 74% [95% confidence interval (95%CI): 60-85%], specificity 91% (95%CI: 85-96%), LR+ 5.56 (95%CI: 2.02-15.27), LR- 0.37 (95%CI: 0.10-1.35), and DOR 16.96 (95%CI: 2.06-139.66). The area under the summary ROC curve was 0.874. |
Good |
| 46. Lauri C, Glaudemans AWJM, Campagna G, et al. Comparison of White Blood Cell Scintigraphy, FDG PET/CT and MRI in Suspected Diabetic Foot Infection: Results of a Large Retrospective Multicenter Study. Journal of Clinical Medicine. 9(6), 2020 May 30. |
Observational-Dx |
251 patients |
The aim of this multicenter retrospective study was to compare the diagnostic accuracy of white blood cell scintigraphy (WBC), 18F-fluorodeoxyglucose positron emission tomography/computed tomography ((18F) FDG PET/CT), and Magnetic Resonance Imaging (MRI) in patients with suspected DFI. |
Images and clinical data from 251 patients enrolled by five centers were collected in order to calculate the sensitivity, specificity, and accuracy of WBC, FDG, and MRI in diagnosing osteomyelitis (OM), soft-tissue infection (STI), and Charcot osteoarthropathy. In OM, WBC acquired following the European Society of Nuclear Medicine (EANM) guidelines was more specific and accurate than MRI (91.9% vs. 70.7%, p < 0.0001 and 86.2% vs. 67.1%, p = 0.003, respectively). In STI, both FDG and WBC achieved a significantly higher specificity than MRI (97.9% and 95.7% vs. 83.6%, p = 0.04 and p = 0.018, respectively). In Charcot, both MRI and WBC demonstrated a significantly higher specificity and accuracy than FDG (88.2% and 89.3% vs. 62.5%, p = 0.0009; 80.3% and 87.9% vs. 62.1%, p < 0.02, respectively). Moreover, in Charcot, WBC was more specific than MRI (89.3% vs. 88.2% p < 0.0001). |
2 |
| 47. Al-Balas H, Metwalli ZA, Nagaraj A, Sada DM. Is fluoroscopy-guided percutaneous bone biopsy of diabetic foot with suspected osteomyelitis worthwhile? A retrospective study. Journal Of Diabetes. 15(4):332-337, 2023 Apr. |
Review/Other-Dx |
170 biopsies |
The aim of this study is to report the yield of percutaneous bone biopsy in persons with diabetes with clinically suspected osteomyelitis involving the foot and the spectrum of offending pathogens recovered from these biopsies. |
Microbiological cultures of 80 samples (47.1%) were positive with 53.8% of the positive culture showed monomicrobial growth and the remaining were polymicrobial. Of the positive bone samples 71.3% grew Gram-positive bacteria. Staphylococcus aureus was the most frequently isolated pathogen from positive bone cultures with almost one third showing methicillin resistence. Enterococcus species were the most frequently isolated pathogens from polymicrobial samples. Enterobacteriaceae species were the most common Gram-negative pathogens and were more common in polymicrobial samples. |
4 |
| 48. Heidari N, Kwok I, Vris A, Charalambous A. Should Treatment of Diabetic Foot Osteomyelitis Be Based on Bone Biopsies?. Foot & Ankle International. 40(1_suppl):73S-74S, 2019 Jul. |
Review/Other-Dx |
NA |
No abstract available. |
No abstract available. |
4 |
| 49. Said N, Chalian M, Fox MG, Nacey NC. Percutaneous image-guided bone biopsy of osteomyelitis in the foot and pelvis has a low impact on guiding antibiotics management: a retrospective analysis of 60 bone biopsies. Skeletal Radiology. 48(9):1385-1391, 2019 Sep. |
Review/Other-Dx |
60 bone biopsies |
The objective of the study is to determine the culture positivity rate and clinical utility of bone biopsy in guiding the management of patients with osteomyelitis. |
A total of 60 bone biopsies met the inclusion criteria, 25 within the foot and 35 biopsies of the pelvis. Overall, 11 out of 60 core biopsies (18%) yielded positive cultures. Antibiotics management was altered in only 27% patients with a positive culture; thus, only 5% of patients with MRI findings of osteomyelitis undergoing biopsy had an impact on management. |
4 |
| 50. Schechter MC, Ali MK, Risk BB, et al. Percutaneous Bone Biopsy for Diabetic Foot Osteomyelitis: A Systematic Review and Meta-Analysis. Open Forum Infectious Diseases. 7(10):ofaa393, 2020 Oct. |
Meta-analysis |
861 articles |
The main goal of this study is to report on the microbiological yield of PBBs among patients with DFO (ie, proportion that are culture-positive). In addition, we sought to describe the bacterial species recovered by PBB and report on aggregated procedure-related adverse events, DFO outcomes, and antibiotic regimen adjustment according to PBB culture results. |
Among 861 articles, 11 studies met inclusion criteria and included 780 patients with 837 PBBs. Mean age ranged between 56.6 and 71.0 years old. The proportion of males ranged from 62% to 86%. All studies were longitudinal observational cohorts, and 10 were from Europe. The range of culture-positive PBBs was 56%-99%, and the pooled proportion of PBBs with a positive culture was 84% (95% confidence interval, 73%-91%). There was heterogeneity between studies and no consistency in definitions used to define adverse events. Impact of PBB on DFO outcomes or antibiotic management were seldom reported. |
Good |
| 51. Tardaguila-Garcia A, Sanz-Corbalan I, Garcia-Morales E, Garcia-Alvarez Y, Molines-Barroso RJ, Lazaro-Martinez JL. Diagnostic Accuracy of Bone Culture Versus Biopsy in Diabetic Foot Osteomyelitis. Advances in Skin & Wound Care. 34(4):204-208, 2021 Apr 01. |
Observational-Dx |
52 patients |
To compare the diagnostic accuracy of bone culture (microbiology) and biopsy (histology) in patients with acute or chronic diabetic foot osteomyelitis (DFO). |
Fifty-two patients were included; 69% had positive bone culture results, and 90.4% had positive histology results (P = .013), and of those 90.4%, 25.5% had acute and 74.5% had chronic DFO. The sensitivity of the microbiologic bone culture result was 0.70, the specificity was 0.40, the positive predictive value was 0.92, and the negative predictive value was 0.13. |
2 |
| 52. Al-Khawari HA, Al-Saeed OM, Jumaa TH, Chishti F. Evaluating diabetic foot infection with magnetic resonance imaging: Kuwait experience. Med Princ Pract. 2005; 14(3):165-172. |
Observational-Dx |
29 diabetic patients with suspected infection |
To evaluate the capability of MRI to depict and characterize the changes seen in diabetic foot infections. |
MRI showed osteomyelitis in 14 patients, abscess in 5, cellulitis in 26, tenosynovitis in 4 and neuropathic joint in 8. 3 cases were normal. Pathological confirmations were obtained in 19 patients. MRI and histological diagnosis were in concordance in 79% of osteomyelitis cases, 100% of neuropathy cases and 100% of cellulitis cases. The sensitivity and specificity of MRI in diagnosing osteomyelitis were 100% and 63% respectively. PPV and NPV, and accuracy were 79%, 100% and 84%, respectively. MRI is a sensitive and accurate imaging modality for the evaluation of foot infections in diabetic patients and for planning proper treatment. |
3 |
| 53. Rozzanigo U, Tagliani A, Vittorini E, Pacchioni R, Brivio LR, Caudana R. Role of magnetic resonance imaging in the evaluation of diabetic foot with suspected osteomyelitis. Radiol Med (Torino). 114(1):121-32, 2009 Feb. |
Observational-Dx |
16 patients with infected ulcers |
To evaluate MRI in infected diabetic foot ulcers. |
The final diagnosis, based on clinical imaging, microbiological and histological findings, was osteomyelitis in 13/16 cases. Foot MRI allowed a correct diagnosis in 15/16 patients, with one false positive result demonstrated by CT-guided bone biopsy. MRI has high sensitivity for the detection of osteomyelitis in the diabetic foot but lower specificity related to Charcot neuropathic osteoarthropathy. |
3 |
| 54. Sax AJ, Halpern EJ, Zoga AC, Roedl JB, Belair JA, Morrison WB. Predicting osteomyelitis in patients whose initial MRI demonstrated bone marrow edema without corresponding T1 signal marrow replacement. Skeletal Radiology. 49(8):1239-1247, 2020 Aug. |
Observational-Dx |
60 pedal ulcers |
We endeavored to determine which characteristics of diabetic ulcers portend the strongest risk for osteomyelitis in patients whose initial T1-weighted imaging was normal. By determining which features have a greater risk for osteomyelitis, clinicians can treat patients more aggressively to reduce the sequela of inadequately treated osteomyelitis. |
Sixty MR exams were identified. Thirty-four progressed to osteomyelitis. Marrow ROI/joint fluid ratios averaged 65% in the osteomyelitis group, and 45% in the non-osteomyelitis group, p < 0.001. ROI ratios > 53% had a 6.5-fold increased risk of osteomyelitis, p < 0.001. Proximity to bone averaged 6 mm in the osteomyelitis group and 9 mm in the non-osteomyelitis group, p = 0.02. Ulcer size averaged 4 cm2 in the osteomyelitis group versus 2.4 cm2 in the non-osteomyelitis group, p = 0.07. Ulcers greater than 3 cm2 has a 2-fold increase in the risk of osteomyelitis, p = 0.04 |
3 |
| 55. Kapoor A, Page S, Lavalley M, Gale DR, Felson DT. Magnetic resonance imaging for diagnosing foot osteomyelitis: a meta-analysis. [Review] [38 refs]. Arch Intern Med. 167(2):125-32, 2007 Jan 22. |
Meta-analysis |
16 studies |
To determine the diagnostic test performance of MRI for osteomyelitis of the foot and compared this performance with that of Tc- 99m bone scanning, radiography, and WBC studies. |
In all studies combined, the diagnostic odds ratio for MRI was 42.1 (95% CI, 14.8-119.9), and the specificity at a 90% sensitivity cut point was 82.5%. The diagnostic odds ratio did not vary greatly among subsets of studies. In studies in which a direct comparison could be made with other technologies, the diagnostic odds ratio for MRI was consistently better than that for bone scanning (7 studies; 149.9 vs 3.6), radiography (9 studies; 81.5 vs 3.3), and WBC studies (3 studies; 120.3 vs 3.4). MRI performs well in the diagnosis of osteomyelitis of the foot and ankle and can be used to rule in or rule out the diagnosis. MRI performance was markedly superior to that of Tc-99m bone scanning, radiography, and WBC studies. |
M |
| 56. Craig JG, Amin MB, Wu K, et al. Osteomyelitis of the diabetic foot: MR imaging-pathologic correlation. Radiology. 203(3):849-55, 1997 Jun. |
Observational-Dx |
13 patients |
To evaluate the efficacy of magnetic resonance (MR) imaging for the diagnosis of osteomyelitis in the diabetic foot by using anatomic and histologic studies of the resected tissue as a standard of reference. |
Maximum signal intensity on the T2-weighted or short inversion time inversion-recovery images of the bones was due to osteomyelitis (prospective sensitivity, 90%; specificity, 71%). Eighteen bones with increased signal intensity showed only edema of the marrow. The range of signal intensity in edema overlapped that in osteomyelitis but was lower. The use of gadopentetate dimeglumine improved delineation of soft-tissue inflammatory masses, but this contrast material was not useful in distinguishing osteomyelitis from edema. |
3 |
| 57. 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 |
| 58. 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 |
| 59. 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 |
| 60. Tiegs-Heiden CA, Anderson TC, Collins MS, Johnson MP, Osmon DR, Wenger DE. Outcomes in patients with clinically suspected pedal osteomyelitis based on bone marrow signal pattern on MRI. Journal Of Bone And Joint Infection. 8(2):99-107, 2023. |
Observational-Dx |
112 patients |
The purpose of this study was to address this issue by comparing the rate of osteomyelitis and amputation based on T1 marrow signal characteristics. |
patients with confluent T1 hypointense signal on MRI had significantly higher rates of osteomyelitis and amputation at 2 and 14 months post-MRI than the reticulated T1 hypointense group ( p<0.001p<0.001 ). Six patients had normal T1 signal, 16.7 % of whom had osteomyelitis and underwent amputation by 2 months post-MRI. Of 61 patients with reticulated T1 hypointense signal, 19.7 % had a diagnosis of osteomyelitis at 2 months post-MRI and 30.8 % had a diagnosis of osteomyelitis at 14 months post-MRI; moreover, 14.8 % and 31.5 % underwent amputation by 2 and 14 months post-MRI, respectively. Of 45 patients with confluent T1 hypointense signal, 73.3 % of patients had osteomyelitis at 2 months post-MRI and 82.5 % had osteomyelitis at 14 months post-MRI. In this group, 66.7 % underwent amputation by 2 months post-MRI and 77.8 % underwent amputation by 14 months post-MRI. |
3 |
| 61. Schwegler B, Stumpe KD, Weishaupt D, et al. Unsuspected osteomyelitis is frequent in persistent diabetic foot ulcer and better diagnosed by MRI than by 18F-FDG PET or 99mTc-MOAB. J Intern Med. 2008; 263(1):99-106. |
Observational-Dx |
20 diabetic patients with foot ulcers; 7+ for osteomyelitis by biopsy |
To assess the prevalence of clinically unsuspected osteomyelitis and to compare the value of MRI, FDG-PET and 99mTc-labelled monoclonal antigranulocyte antibody scintigraphy. |
Clinically unsuspected osteomyelitis is frequent in persisting foot ulcers and is a high risk factor for adverse outcome. MRI appears superior to FDG-PET and 99mTc-labelled monoclonal antigranulocyte antibody scintigraphy in detecting foot ulcer-associated osteomyelitis. MRI was positive in 6/7 patients with proven osteomyelitis, whereas FDG-PET and 99mTc-labelled monoclonal antigranulocyte antibody scintigraphy were positive only in (the same) two patients. Clinically unsuspected osteomyelitis is frequent in persisting foot ulcers and is a high risk factor for adverse outcome. MRI appears superior to FDG-PET and 99mTc-labelled monoclonal antigranulocyte antibody scintigraphy in detecting foot ulcer-associated osteomyelitis and might be the preferred imaging modality in patients with nonhealing diabetic foot ulcers. |
2 |
| 62. Vesco L, Boulahdour H, Hamissa S, et al. The value of combined radionuclide and magnetic resonance imaging in the diagnosis and conservative management of minimal or localized osteomyelitis of the foot in diabetic patients. Metabolism. 1999; 48(7):922-927. |
Observational-Dx |
24 patients |
To evaluate combined bone scan, labeled white cells, and MRI. |
Evidence of osteomyelitis was based on the presence of at least one of the following criteria: 1) Clinical bone involvement, 2) Radiological bone involvement, 3) Both positive combined radionuclide imaging and MRI, and 4) Evidence of clinical bone involvement during the follow-up period. 13 patients had osteomyelitis. 7 patients had clinical bone involvement (sensitivity, 54%), 5 patients had radiological bone involvement (sensitivity, 38%), and 10 had positive combined radionuclide imaging for osteomyelitis (sensitivity, 77%). MRI demonstrated a higher sensitivity (100%). The specificity for combined radionuclide imaging and MRI was 82%. These results lead to a new diagnostic strategy for the early detection of minimal or localized osteomyelitis to avoid amputations. MRI is most appropriate following a negative radiograph in determining whether to treat osteomyelitis, since a negative MRI result rules out osteomyelitis. Antibiotic therapy should be used in the case of a positive MRI result, but Charcot joint disease can lead to false-positive MRI results. In this case, combined radionuclide imaging should be performed. |
3 |
| 63. Horowitz JD, Durham JR, Nease DB, Lukens ML, Wright JG, Smead WL. Prospective evaluation of magnetic resonance imaging in the management of acute diabetic foot infections. Ann Vasc Surg. 1993; 7(1):44-50. |
Observational-Dx |
41 diabetic patients |
Prospective study to evaluate the ability of MRI to manage acute diabetic foot infections. |
Based on clinical outcome during the acute hospitalization period, operative findings, and/or pathologic confirmation, the PPV of MRI in defining infectious pathology in the foot was 100% in this series of 20 positive scans. The NPV of MRI was 96%. MRI is a diagnostic modality particularly well suited to evaluate acute diabetic foot infections and reliably aids in the management of acute infection to avoid exploration and debridement of uninvolved tissue. |
3 |
| 64. Kotecha HM, Lo HS, Vedantham S, Shin H, Cerniglia CA. Abbreviated MRI of the foot in patients with suspected osteomyelitis. Emergency Radiology. 27(1):9-16, 2020 Feb. |
Observational-Dx |
102 patients |
To determine the diagnostic accuracy of an abbreviated magnetic resonance imaging (MRI) protocol of the foot for the diagnosis of osteomyelitis in patients with acute foot infection. |
One hundred and two MRI examinations met inclusion criteria; participants ranged in age from 26 to 91 years, with a mean age of 59 years. Seventy examinations were performed for male participants (69%) and 32 for female participants (31%). Thirty-five had a confirmed diagnosis of osteomyelitis, while the remainder (n = 67) did not. An average of 6 non-contrast sequences was performed during each examination. The most common protocol (53/102 examinations) was comprised of the following 6 sequences: axial T1-weighted, axial fat-saturated proton density, sagittal T1-weighted, sagittal T2-weighted FMPIR, coronal T1-weighted, and coronal fat-saturated proton density. After patient positioning, the abbreviated protocol sequences (sagittal T2-weighted FMPIR and coronal T1-weighted) were performed in an average total of 8 min. The reference standard protocol required an average of 22 min to complete 6 sequences. Averaged across all readers, the AUC for the reference standard full protocol and the abbreviated protocols were 0.843 and 0.873, respectively. The difference in AUC between protocols was not statistically significant (p = 0.1297), with the abbreviated protocol showing a non-significantly greater AUC. |
2 |
| 65. Lopez-Moral M, Garcia-Madrid M, Molines-Barroso RJ, Garcia-Alvarez Y, Alvaro-Afonso FJ, Lazaro-Martinez JL. Diagnostic Performance of Ultrasonography for Diabetic Foot Osteomyelitis. Advances in Wound Care. 2023 Dec 20. |
Observational-Dx |
24 patients |
This study aims to analyze the potential diagnostic capability of ultrasonography (US) in detecting diabetic foot osteomyelitis (DFO) in patients with diabetic foot ulcers (DFUs). |
All patients (n = 24) diagnosed with DFO exhibited positive power Doppler, resulting in a sensitivity (S) and specificity (SP) of 1 and an area under the curve (AUC) of 1 (p < 0.001 [1-1]). Cortical disruption was present in 23 patients (95.8%) with DFO, yielding an S of 0.93, SP of 1, and AUC of 0.96 (p < 0.001 [0.88-1]). |
2 |
| 66. Palestro CJ, Love C, Miller TT. Infection and musculoskeletal conditions: Imaging of musculoskeletal infections. [Review] [95 refs]. Baillieres Best Pract Res Clin Rheumatol. 20(6):1197-218, 2006 Dec. |
Review/Other-Dx |
N/A |
To review imaging of musculoskeletal infections. |
MRI is sensitive, provides superb anatomic detail, does not use ionizing radiation, and is rapidly completed. This technique is especially valuable for septic arthritis, spinal osteomyelitis, and diabetic foot infections. Among the radionuclide procedures, three-phase bone imaging is readily available, and very accurate in unviolated bone. Labeled leukocyte imaging should be used in cases of ‘complicating osteomyelitis’ such as prosthetic joint infections. This test is also useful in unsuspected diabetic pedal osteomyelitis and the neuropathic joint. Gallium imaging is a useful adjunct to MRI in spinal infection. FDG-PET will likely play an important role, especially in the evaluation of spinal infection. |
4 |
| 67. Al-Sheikh W, Sfakianakis GN, Mnaymneh W, et al. Subacute and chronic bone infections: diagnosis using In-111, Ga-67 and Tc-99m MDP bone scintigraphy, and radiography. Radiology 1985;155:501-6. |
Observational-Dx |
21 patients |
To evaluate the usefulness of indium-111 white blood cell scintigraphy in the diagnosis of subacute or chronic bone infection. |
In-111 WBC scintigraphy showed no definite advantage over Ga-67 scintigraphy in the identification of chronic bone infection. The two tests had the same sensitivity (80%) and similar specificity (In-111 WBC 75%, Ga-67 83%; difference not significant). Bone radiography had a sensitivity of 60% and a specificity of 67%. A negative Tc-99m MDP bone scintigram ruled out infection (sensitivity 100%), but because of low specificity (25%), final evaluation required performance of Ga-67 or In-111 WBC scintigraphy. |
3 |
| 68. Palestro CJ, Love C, Tronco GG, Tomas MB, Rini JN. Combined labeled leukocyte and technetium 99m sulfur colloid bone marrow imaging for diagnosing musculoskeletal infection. Radiographics. 2006;26:859-70. |
Review/Other-Dx |
N/A |
To review combined labeled leukocyte and Tc-99m sulfur colloid bone marrow imaging for diagnosing musculoskeletal infection. |
Combined WBC-marrow imaging is a very accurate technique for diagnosing osteomyelitis. |
4 |
| 69. Park SB, Lim CH, Chun DI, Kim YJ, Kim TH, Park JM. The usefulness of quantitative (99m)Tc-HMPAO WBC SPECT/CT for predicting lower extremity amputation in diabetic foot infection. Sci Rep 2024;14:9260. |
Observational-Dx |
83 patients |
We investigated the usefulness of quantitative 99mTc-white blood cell (WBC) single photon emission computed tomography (SPECT)/computed tomography (CT) for predicting lower extremity amputation in diabetic foot infection (DFI). |
Statistical logistic regression analysis was performed to explore the predictors of LEA and receiver operating characteristic (ROC) curve was analysed to assess the predictive value of SPECT/CT. The independent predictors of amputation were previous amputation (OR 11.9), numbers of SPECT/CT lesions (OR 2.1), and SUVmax of DFI; either continuous SUVmax (1-increase) (OR 1.3) or categorical SUVmax > 1.1 (OR 21.6). However, the conventional SPECT/CT interpretation failed to predict amputation. In ROC analysis, the SUVmax yielded a fair predictor (area under the curve (AUC) 0.782) of amputation. The model developed from these independent predictors yielded an excellent performance for predicting amputation (AUC 0.873). Quantitative WBC SPECT/CT can provide new information useful for predicting the outcomes and guiding treatment for patients with DFI. |
2 |
| 70. Cohen M, Cerniglia B, Gorbachova T, Horrow J. Added value of MRI to X-ray in guiding the extent of surgical resection in diabetic forefoot osteomyelitis: a review of pathologically proven, surgically treated cases. Skeletal Radiology. 48(3):405-411, 2019 Mar. |
Review/Other-Dx |
32 cases |
This study retrospectively evaluated the added value of MRI over X-ray in guiding the extent of amputation in a cohort of patients with surgically treated, pathologically proven osteomyelitis. |
In 9 cases that were positive on both modalities, MRI identified an average of 1.2 additional bone segments of disease. There was surgical agreement with X-ray in 3 out of 31 cases (9.7%, 95%CI 0-20.1) and with MRI in 17 out of 31 cases (55%, 37.3-72.4; p < 0.0001). There was an added value of MRI over X-ray in guiding surgical treatment in 64.5% of cases (95% CI 47.7%-81.4%). MRI added value in 5 out of 9 X-rays positive for osteomyelitis and in 15 out of 22 negative (p value was not significant). |
4 |
| 71. Ledermann HP, Schweitzer ME, Morrison WB. Nonenhancing tissue on MR imaging of pedal infection: characterization of necrotic tissue and associated limitations for diagnosis of osteomyelitis and abscess. AJR Am J Roentgenol. 178(1):215-22, 2002 Jan. |
Observational-Dx |
110 foot exams in 102 patients |
To study the frequency, location, extent, and signal characteristics of nonenhancing tissue in pedal infections and correlated those areas with surgical and histologic findings. |
Signal characteristics on T1-weighted images were isointense to muscle (n=21, 77.8%), hypointense to muscle (n=3, 11.1%), heterogeneous (n=2, 7.4%), and isointense to fat (n=1, 3.7%). On T2-weighted images, the signal was hyperintense to muscle (n=12, 44.4%), heterogeneous to muscle (n=9, 33.3%), equal to fluid (n=3, 11.1%), and hypointense to muscle (n=3, 11.1%). The mean signal increase after contrast administration was 3.57% for observer 1 and 2.68% for observer 2. Necrotic tissue was surgically confirmed in the nonenhancing areas in 26 feet (96.3%). Nonenhancing areas are seen in one fourth of pedal infections, occur almost exclusively in diabetic patients, and represent necrotic tissue. Only contrast-enhanced images allow reliable recognition of these regions. Lack of enhancement in these areas can mask the presence of abscess and osteomyelitis. |
2 |
| 72. Hopfner S, Krolak C, Kessler S, et al. Preoperative imaging of Charcot neuroarthropathy in diabetic patients: comparison of ring PET, hybrid PET, and magnetic resonance imaging. Foot Ankle Int. 25(12):890-5, 2004 Dec. |
Observational-Dx |
16 patients with type II diabetes |
To investigate the value of two types of PET in the preoperative evaluation of diabetic patients with Charcot foot deformities. |
Of 39 Charcot lesions confirmed at surgery, 37 were detected by ring PET, 30 by hybrid PET, and 31 by MRI. PET (ring or hybrid) can be used in the evaluation of patients with metal implants that would compromise the accuracy of MRI. Another advantage of PET is its ability to distinguish between inflammatory and infectious soft-tissue lesions, and between osteomyelitis and Charcot neuroarthropathy. The differentiation between Charcot neuroarthropathy and florid osteomyelitis provides the surgeon with important additional information that often is unavailable from MRI. Because it provides important additional data, ring PET may be preferable to radiography and MRI in the preoperative evaluation of patients with Charcot neuroarthropathy of the foot. Hybrid PET, because of its poorer resolution compared to ring PET, appears less suitable for routine clinical application. |
2 |
| 73. Chacko TK, Zhuang H, Nakhoda KZ, Moussavian B, Alavi A. Applications of fluorodeoxyglucose positron emission tomography in the diagnosis of infection. Nucl Med Commun. 2003;24(6):615-624. |
Observational-Dx |
167 scans to evaluate 175 potential sites of infection |
To assess the accuracy of FDG-PET in diagnosing infection in a large population of patients and in a variety of clinical circumstances where the performance of conventional imaging modalities has been questioned. |
The overall accuracy of FDG-PET in evaluating orthopedic hardware was 96.2% for hip prosthesis, 81% for knee prosthesis, and 100% in 15 patients with other orthopedic devices. Among the patients in the sample suspected of having chronic osteomyelitis, the accuracy was 91.2%. FDG-PET was inaccurate in 3 cases of fever of unknown origin and accurate in all vascular graft and soft tissue infections. In 49 patients with a clinically apparent soft-tissue infection, FDG-PET was able to detect or exclude underlying osteomyelitis with an accuracy of 92.3%. Among the 23 patients who had recent orthopedic procedures, FDG-PET imaging was accurate in 87% of cases. |
3 |
| 74. Crymes WB, Jr., Demos H, Gordon L. Detection of musculoskeletal infection with 18F-FDG PET: review of the current literature. J Nucl Med Technol. 2004;32(1):12-15. |
Review/Other-Dx |
7 articles; 273 cases of suspected musculoskeletal infection |
Literature search was performed to determine the effectiveness of FDG-PET in the evaluation of musculoskeletal infection. |
The current literature suggests that FDG-PET is a highly accurate method to detect musculoskeletal infection. |
4 |
| 75. 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 |
| 76. Porrino J, Wang A, Moats A, Mulcahy H, Kani K. Prosthetic joint infections: diagnosis, management, and complications of the two-stage replacement arthroplasty. Skeletal radiology 2020;49:847-59. |
Review/Other-Dx |
NA |
We describe the classification of prosthetic joint infections, the clinical and imaging diagnosis, and treatment strategies. |
No results listed in abstract. |
4 |
| 77. Park BN, Hong SJ, Yoon MA, Oh JK. MRI Diagnosis for Post-Traumatic Osteomyelitis of Extremities Using Conventional Metal-Artifact Reducing Protocols: Revisited. Acad Radiol. 26(11):e317-e323, 2019 11. |
Observational-Dx |
261 patients |
To assess the diagnostic power of MR imaging features for post-traumatic osteomyelitis (PTOM) of the extremities with metal implants using a 3.0-T machine with conventional metal-artifact reducing (MAR) protocols. |
The sensitivity, specificity, positive and negative predictive values, and accuracy of MR diagnosis by two observers were 55%/38%, 81%/93%, 67%/40%, 73%/78%, and 71%/71%, respectively. Among the findings, T1 low signal intensity, medullary location, confluent pattern, typical features (concurrence of T1 low signal intensity, medullary, and confluent patterns), heterogeneous or no enhancement, and cortical destruction were statistically significant by univariate analysis (p<0.05). Among these features, only medullary involvement was significant by multivariate analysis (p = 0.007). Medullary involvement and no enhancement pattern were significant by step-wise discrimination analysis. Interobserver correlation was moderate with a weighted kappa value of 0.512 (confidence interval: 0.3-0.723). |
3 |
| 78. National Academies of Sciences, Engineering, and Medicine; Division of Behavioral and Social Sciences and Education; Committee on National Statistics; Committee on Measuring Sex, Gender Identity, and Sexual Orientation. Measuring Sex, Gender Identity, and Sexual Orientation. In: Becker T, Chin M, Bates N, eds. Measuring Sex, Gender Identity, and Sexual Orientation. Washington (DC): National Academies Press (US) Copyright 2022 by the National Academy of Sciences. All rights reserved.; 2022. |
Review/Other-Dx |
N/A |
Sex and gender are often conflated under the assumptions that they are mutually determined and do not differ from each other; however, the growing visibility of transgender and intersex populations, as well as efforts to improve the measurement of sex and gender across many scientific fields, has demonstrated the need to reconsider how sex, gender, and the relationship between them are conceptualized. |
No abstract available. |
4 |
| 79. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf. |
Review/Other-Dx |
N/A |
To provide evidence-based guidelines on exposure of patients to ionizing radiation. |
No abstract available. |
4 |
