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Debs P, Boutin RD, Smith SE, Babic M, Blankenbaker D, Chandra V, Murphey M, Thottacherry E, Kreulen C, Fayad LM. Chronic Nonspinal Osteomyelitis in Adults: Consensus Recommendations on Percutaneous Bone Biopsies from the Society of Academic Bone Radiologists. Radiology 2024; 311:e231348. [PMID: 38625010 PMCID: PMC11070610 DOI: 10.1148/radiol.231348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
The diagnosis and management of chronic nonspinal osteomyelitis can be challenging, and guidelines regarding the appropriateness of performing percutaneous image-guided biopsies to acquire bone samples for microbiological analysis remain limited. An expert panel convened by the Society of Academic Bone Radiologists developed and endorsed consensus statements on the various indications for percutaneous image-guided biopsies to standardize care and eliminate inconsistencies across institutions. The issued statements pertain to several commonly encountered clinical presentations of chronic osteomyelitis and were supported by a literature review. For most patients, MRI can help guide management and effectively rule out osteomyelitis when performed soon after presentation. Additionally, in the appropriate clinical setting, open wounds such as sinus tracts and ulcers, as well as joint fluid aspirates, can be used for microbiological culture to determine the causative microorganism. If MRI findings are positive, surgery is not needed, and alternative sites for microbiological culture are not available, then percutaneous image-guided biopsies can be performed. The expert panel recommends that antibiotics be avoided or discontinued for an optimal period of 2 weeks prior to a biopsy whenever possible. Patients with extensive necrotic decubitus ulcers or other surgical emergencies should not undergo percutaneous image-guided biopsies but rather should be admitted for surgical debridement and intraoperative cultures. Multidisciplinary discussion and approach are crucial to ensure optimal diagnosis and care of patients diagnosed with chronic osteomyelitis.
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Affiliation(s)
- Patrick Debs
- From The Russell H. Morgan Department of Radiology and Radiological Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department, Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.); Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department of Orthopaedic Surgery, University of California-Davis, Sacramento, Calif (C.K.)
| | - Robert D Boutin
- From The Russell H. Morgan Department of Radiology and Radiological Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department, Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.); Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department of Orthopaedic Surgery, University of California-Davis, Sacramento, Calif (C.K.)
| | - Stacy E Smith
- From The Russell H. Morgan Department of Radiology and Radiological Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department, Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.); Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department of Orthopaedic Surgery, University of California-Davis, Sacramento, Calif (C.K.)
| | - Maja Babic
- From The Russell H. Morgan Department of Radiology and Radiological Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department, Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.); Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department of Orthopaedic Surgery, University of California-Davis, Sacramento, Calif (C.K.)
| | - Donna Blankenbaker
- From The Russell H. Morgan Department of Radiology and Radiological Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department, Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.); Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department of Orthopaedic Surgery, University of California-Davis, Sacramento, Calif (C.K.)
| | - Venita Chandra
- From The Russell H. Morgan Department of Radiology and Radiological Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department, Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.); Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department of Orthopaedic Surgery, University of California-Davis, Sacramento, Calif (C.K.)
| | - Mark Murphey
- From The Russell H. Morgan Department of Radiology and Radiological Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department, Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.); Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department of Orthopaedic Surgery, University of California-Davis, Sacramento, Calif (C.K.)
| | - Elizabeth Thottacherry
- From The Russell H. Morgan Department of Radiology and Radiological Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department, Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.); Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department of Orthopaedic Surgery, University of California-Davis, Sacramento, Calif (C.K.)
| | - Christopher Kreulen
- From The Russell H. Morgan Department of Radiology and Radiological Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department, Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.); Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department of Orthopaedic Surgery, University of California-Davis, Sacramento, Calif (C.K.)
| | - Laura M Fayad
- From The Russell H. Morgan Department of Radiology and Radiological Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department, Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.); Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department of Orthopaedic Surgery, University of California-Davis, Sacramento, Calif (C.K.)
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Mens MA, de Geus A, Wellenberg RHH, Streekstra GJ, Weil NL, Bus SA, Busch-Westbroek TE, Nieuwdorp M, Maas M. Preliminary evaluation of dual-energy CT to quantitatively assess bone marrow edema in patients with diabetic foot ulcers and suspected osteomyelitis. Eur Radiol 2023; 33:5645-5652. [PMID: 36820925 PMCID: PMC10326105 DOI: 10.1007/s00330-023-09479-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 12/19/2022] [Accepted: 01/24/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVES 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. METHODS Patients with a diabetic foot ulcer and suspected osteomyelitis that underwent DECT (80 kVp/Sn150 kVp) with VNCa were retrospectively included. Two observers independently measured CT values of the bone adjacent to the ulcer and a reference bone not related to the ulcer. The patients were divided into two clinical groups, osteomyelitis or no-osteomyelitis, based on the final diagnosis by the treating physicians. RESULTS 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%. CONCLUSION DECT with VNCa has a potential value for quantitatively assessing the presence of BME in patients with diabetic foot ulcers and suspected osteomyelitis. KEY POINTS • Dual-energy CT (DECT) with virtual non-calcium (VNCa) is promising for detecting bone marrow edema in the case of diabetic foot ulcers with suspected osteomyelitis. • DECT with VNCa has the potential to become a more practical alternative to MRI in assessing the presence of bone marrow edema in suspected osteomyelitis when radiographs are not sufficient to form a diagnosis.
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Affiliation(s)
- M A Mens
- Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, The Netherlands.
| | - A de Geus
- Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, The Netherlands
| | - R H H Wellenberg
- Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, The Netherlands
| | - G J Streekstra
- Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, The Netherlands
- Biomedical Engineering and Physics, Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - N L Weil
- Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, The Netherlands
| | - S A Bus
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, The Netherlands
- Rehabilitation Medicine, Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - T E Busch-Westbroek
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, The Netherlands
- Rehabilitation Medicine, Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - M Nieuwdorp
- Internal Medicine, Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Diabetes and Metabolism, Amsterdam, The Netherlands
| | - M Maas
- Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, The Netherlands
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