Skip to main content

Advertisement

SpringerLink
Log in

Performance of a rapid two-sequence screening protocol for osteomyelitis of the foot

  • Scientific Article
  • Published:
Skeletal Radiology Aims and scope Submit manuscript

Abstract

Objective

Compare a two sequence protocol to a standard protocol in the detection of pedal osteomyelitis (OM) and abscesses and to identify patients that benefit from a full protocol.

Materials and methods

One hundred thirty-two foot MRIs ordered to assess for OM were enrolled, and the following items were extracted from the clinical reports: use of IV contrast, the presence of OM, reactive osteitis, and a soft tissue abscess. Using only one T1 nonfat-suppressed and one fluid sensitive fat-suppressed sequences, two experienced musculoskeletal radiologists reviewed each case for the presence of OM, reactive osteitis, or an abscess. A Kappa test was calculated to assess for interobserver agreement, and diagnostic performance was determined. The McNemar test was used to assess for the effect of contrast.

Results

Agreement between both observers and the clinical report on the presence of osteomyelitis was substantial ( k = 0.63 and 0.72, p < 0.001), while the agreement for abscess was fair (k = 0.29 and 0.38, p < 0.001). For osteomyelitis, both observers showed good accuracy (0.85 and 0.86). When screening bone for a normal versus abnormal case, this method was highly sensitive (0.97–0.98), but was less sensitive for abscess (0.63–0.75). Fifty-one percent of exams used contrast, and it did impact the diagnosis of abscess for one observer.

Conclusion

This rapid protocol is accurate in making the diagnosis of OM, and its high sensitivity makes it useful to screen for patients that would benefit from a full protocol.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

Abbreviations

OM:

Osteomyelitis

RO:

Reactive osteitis

EO:

Early osteomyelitis

DFU:

Diabetic foot ulcer

IV:

Intravenous

ACR:

American College of Radiology

BKA:

Below the knee amputation

STIR:

Short tau inversion recovery

References

  1. Geraghty T, LaPorta G. Current health and economic burden of chronic diabetic osteomyelitis. Expert Rev Pharmacoecon Outcomes Res. 2019;19(3):279–86.

    Article  Google Scholar 

  2. Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. N Engl J Med. 2017;376(24):2367–75.

    Article  Google Scholar 

  3. Schweitzer ME, Daffner RH, Weissman BN, Bennett DL, Blebea JS, Jacobson JA, et al. ACR appropriateness criteria on suspected osteomyelitis in patients with diabetes mellitus. J Am Coll Radiol. 2008;5(8):881–6.

    Article  Google Scholar 

  4. 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):165–72.

    Article  Google Scholar 

  5. Ledermann HP, Morrison WB, Schweitzer ME. Pedal abscesses in patients suspected of having pedal osteomyelitis: analysis with MR imaging. Radiology. 2002;224(3):649–55.

    Article  Google Scholar 

  6. Kapoor A, Page S, Lavalley M, Gale DR, Felson DT. Magnetic resonance imaging for diagnosing foot osteomyelitis: a meta-analysis. Arch Intern Med. 2007;167(2):125–32.

    Article  Google Scholar 

  7. Mahendra M, Singh R. Diagnostic accuracy and surgical utility of MRI in complicated diabetic foot. J Clin Diagn Res. 2017;11(7):RC01–4.

    PubMed  PubMed Central  Google Scholar 

  8. Chow I, Lemos EV, Einarson TR. Management and prevention of diabetic foot ulcers and infections: a health economic review. Pharmacoeconomics. 2008;26(12):1019–35.

    Article  Google Scholar 

  9. Kan JH, Estrada C, Hasan U, Bracikowski A, Shyr Y, Shakhtour B, et al. Management of occult fractures in the skeletally immature patient: cost analysis of implementing a limited trauma magnetic resonance imaging protocol. Pediatr Emerg Care. 2009;25(4):226–30.

    Article  Google Scholar 

  10. May LA, Chen DC, Bui-Mansfield LT, O'Brien SD. Rapid magnetic resonance imaging evaluation of femoral neck stress fractures in a U.S. active duty military population. Mil Med. 2017;182(1):e1619–25.

    Article  Google Scholar 

  11. May DA, Disler DG. Screening for avascular necrosis of the hip with rapid MRI: preliminary experience. J Comput Assist Tomogr. 2000;24(2):284–7.

    Article  CAS  Google Scholar 

  12. Ross AB, Chan BY, Yi PH, Repplinger MD, Vanness DJ, Lee KS. Diagnostic accuracy of an abbreviated MRI protocol for detecting radiographically occult hip and pelvis fractures in the elderly. Skelet Radiol. 2019;48(1):103–8.

    Article  Google Scholar 

  13. Khurana B, Okanobo H, Ossiani M, Ledbetter S, Al Dulaimy K, Sodickson A. Abbreviated MRI for patients presenting to the emergency department with hip pain. AJR Am J Roentgenol. 2012;198(6):W581–8.

    Article  Google Scholar 

  14. Khoury NJ, Birjawi GA, Chaaya M, Hourani MH. Use of limited MR protocol (coronal STIR) in the evaluation of patients with hip pain. Skelet Radiol. 2003;32(10):567–74.

    Article  CAS  Google Scholar 

  15. Kotecha HM, Lo HS, Vedantham S, Shin H, Cerniglia CA. Abbreviated MRI of the foot in patients with suspected osteomyelitis. Emerg Radiol. 2019.

  16. Hallgren KA.  Computing Inter-Rater Reliability for Observational Data: An Overview and Tutorial.  Tutor Quant Methods Psychol. 2012;8(1):23–34.

  17. 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"? Skelet Radiol. 2017;46(10):1327–33.

    Article  Google Scholar 

  18. 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. 2002;178(1):215–22.

    Article  Google Scholar 

  19. Morrison WB, Schweitzer ME, Wapner KL, Hecht PJ, Gannon FH, Behm WR. Osteomyelitis in feet of diabetics: clinical accuracy, surgical utility, and cost-effectiveness of MR imaging. Radiology. 1995;196(2):557–64.

    Article  CAS  Google Scholar 

  20. Meyr AJ, Singh S, Zhang X, Khilko N, Mukherjee A, Sheridan MJ, et al. Statistical reliability of bone biopsy for the diagnosis of diabetic foot osteomyelitis. J Foot Ankle Surg. 2011;50(6):663–7.

    Article  Google Scholar 

  21. Chadayammuri V, Herbert B, Hao J, Mavrogenis A, Quispe JC, Kim JW, et al. Diagnostic accuracy of various modalities relative to open bone biopsy for detection of long bone posttraumatic osteomyelitis. Eur J Orthop Surg Traumatol. 2017;27(7):871–5.

    Article  Google Scholar 

  22. Elmarsafi T, Kumar A, Cooper PS, Steinberg JS, Evans KK, Attinger CE, et al. Concordance between bone pathology and bone culture for the diagnosis of osteomyelitis in the presence of Charcot neuro-osteoarthropathy. J Foot Ankle Surg. 2018;57(5):919–23.

    Article  Google Scholar 

  23. Meyr AJ, Seo K, Khurana JS, Choksi R, Chakraborty B. Level of agreement with a multi-test approach to the diagnosis of diabetic foot osteomyelitis. J Foot Ankle Surg. 2018;57(6):1137–9.

    Article  Google Scholar 

  24. Ramanujam CL, Han D, Zgonis T. Medical imaging and laboratory analysis of diagnostic accuracy in 107 consecutive hospitalized patients with diabetic foot osteomyelitis and partial foot amputations. Foot Ankle Spec. 2018;11(5):433–43.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Radiology and Imaging Sciences, Division of Musculoskeletal Imaging, Emory University Hospital, 59 Executive Park South, 4th Floor Suite 4009, Atlanta, GA, 30329, USA

    Adam D. Singer, Monica Umpierrez & Aparna Kakarala

  2. Department of Medicine, Division of Infectious Disease, Emory University Hospital, Atlanta, GA, USA

    Marcos C. Schechter

  3. Department of Orthopaedic Surgery, Emory University Hospital, Atlanta, GA, USA

    Michael Maceroli

  4. University of Calgary, Calgary, Alberta, T2N 1N4, Canada

    Gulshan B. Sharma

  5. Department of Surgery, Division of Vascular Surgery, Emory University Hospital, Atlanta, GA, USA

    Ravi R. Rajani

Authors
  1. Adam D. Singer
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Monica Umpierrez
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Aparna Kakarala
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Marcos C. Schechter
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Michael Maceroli
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Gulshan B. Sharma
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Ravi R. Rajani
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Drs. Umpierrez and Kakarala did the review of the 132 cases. Drs. Maceroli and Rajani provided the surgical insight for the project from an orthopedic and vascualar surgery perspective, respectively. Dr. Schechter provided insight from an infectious disease perspective. Dr. Sharma helped with statistics. All authors were involved in drafting and editing the manuscript.

Corresponding author

Correspondence to Adam D. Singer.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Level of evidence

Level III, Retrospective Cohort

The author(s) declare(s) that they had full access to all of the data in this study and the author(s) take(s) complete responsibility for the integrity of the data and the accuracy of the data analysis.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Singer, A.D., Umpierrez, M., Kakarala, A. et al. Performance of a rapid two-sequence screening protocol for osteomyelitis of the foot. Skeletal Radiol 49, 977–984 (2020). https://doi.org/10.1007/s00256-019-03367-x

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00256-019-03367-x

Keywords

Search

Navigation