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Lauri C, Noriega-Álvarez E, Chakravartty RM, Gheysens O, Glaudemans AWJM, Slart RHJA, Kwee TC, Lecouvet F, Panagiotidis E, Zhang-Yin J, Martinez JLL, Lipsky BA, Uccioli L, Signore A. Diagnostic imaging of the diabetic foot: an EANM evidence-based guidance. Eur J Nucl Med Mol Imaging 2024; 51:2229-2246. [PMID: 38532027 PMCID: PMC11178575 DOI: 10.1007/s00259-024-06693-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/14/2024] [Indexed: 03/28/2024]
Abstract
PURPOSE Consensus on the choice of the most accurate imaging strategy in diabetic foot infective and non-infective complications is still lacking. This document provides evidence-based recommendations, aiming at defining which imaging modality should be preferred in different clinical settings. METHODS This working group includes 8 nuclear medicine physicians appointed by the European Association of Nuclear Medicine (EANM), 3 radiologists and 3 clinicians (one diabetologist, one podiatrist and one infectious diseases specialist) selected for their expertise in diabetic foot. The latter members formulated some clinical questions that are not completely covered by current guidelines. These questions were converted into statements and addressed through a systematic analysis of available literature by using the PICO (Population/Problem-Intervention/Indicator-Comparator-Outcome) strategy. Each consensus statement was scored for level of evidence and for recommendation grade, according to the Oxford Centre for Evidence-Based Medicine (OCEBM) criteria. RESULTS Nine clinical questions were formulated by clinicians and used to provide 7 evidence-based recommendations: (1) A patient with a positive probe-to-bone test, positive plain X-rays and elevated ESR should be treated for presumptive osteomyelitis (OM). (2) Advanced imaging with MRI and WBC scintigraphy, or [18F]FDG PET/CT, should be considered when it is needed to better evaluate the location, extent or severity of the infection, in order to plan more tailored treatment. (3) In a patient with suspected OM, positive PTB test but negative plain X-rays, advanced imaging with MRI or WBC scintigraphy + SPECT/CT, or with [18F]FDG PET/CT, is needed to accurately assess the extent of the infection. (4) There are no evidence-based data to definitively prefer one imaging modality over the others for detecting OM or STI in fore- mid- and hind-foot. MRI is generally the first advanced imaging modality to be performed. In case of equivocal results, radiolabelled WBC imaging or [18F]FDG PET/CT should be used to detect OM or STI. (5) MRI is the method of choice for diagnosing or excluding Charcot neuro-osteoarthropathy; [18F]FDG PET/CT can be used as an alternative. (6) If assessing whether a patient with a Charcot foot has a superimposed infection, however, WBC scintigraphy may be more accurate than [18F]FDG PET/CT in differentiating OM from Charcot arthropathy. (7) Whenever possible, microbiological or histological assessment should be performed to confirm the diagnosis. (8) Consider appealing to an additional imaging modality in a patient with persisting clinical suspicion of infection, but negative imaging. CONCLUSION These practical recommendations highlight, and should assist clinicians in understanding, the role of imaging in the diagnostic workup of diabetic foot complications.
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Affiliation(s)
- Chiara Lauri
- Inflammation and Infection Committee of the European Association of Nuclear Medicine (EANM), Vienna, Austria
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, Faculty of Medicine and Psychology, "Sapienza" University of Rome, Rome, Italy
| | - Edel Noriega-Álvarez
- Inflammation and Infection Committee of the European Association of Nuclear Medicine (EANM), Vienna, Austria
- Department of Nuclear Medicine and Molecular Imaging, University Hospital of Guadalajara, Guadalajara, Spain
| | - Riddhika M Chakravartty
- Inflammation and Infection Committee of the European Association of Nuclear Medicine (EANM), Vienna, Austria
- Radiology Department, Shrewsbury and Telford Hospitals NHS Trust, Shrewsbury, UK
| | - Olivier Gheysens
- Inflammation and Infection Committee of the European Association of Nuclear Medicine (EANM), Vienna, Austria
- Department of Nuclear Medicine and Molecular imaging, University Hospitals Leuven, Leuven, Belgium
| | - Andor W J M Glaudemans
- Inflammation and Infection Committee of the European Association of Nuclear Medicine (EANM), Vienna, Austria.
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
| | - Riemer H J A Slart
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
- Department of Biomedical Photonic Imaging, Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
| | - Thomas C Kwee
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Frédéric Lecouvet
- Department of Radiology, Institut de Recherche Expérimentale et Clinique Cliniques, Universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Emmanouil Panagiotidis
- Bone & Joint Committee of the European Association of Nuclear Medicine (EANM), Vienna, Austria
- Nuclear Medicine Department/PET CT, Theagenio Cancer Center, Thessaloniki, Greece
| | - Jules Zhang-Yin
- Bone & Joint Committee of the European Association of Nuclear Medicine (EANM), Vienna, Austria
- Department of Nuclear Medicine, Clinique Sud Luxembourg, Vivalia, Arlon, Belgium
| | | | - Benjamin A Lipsky
- Emeritus Professor of Medicine, University of Washington, Seattle, USA
- Green Templeton College, University of Oxford, Oxford, UK
| | - Luigi Uccioli
- Diabetes and Endocrinology Section, CTO Hospital of Rome, Rome, Italy
- Department of Biomedicine and prevention, Tor Vergata University, Rome, Italy
| | - Alberto Signore
- Inflammation and Infection Committee of the European Association of Nuclear Medicine (EANM), Vienna, Austria
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, Faculty of Medicine and Psychology, "Sapienza" University of Rome, Rome, Italy
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Calvo-Wright MDM, Álvaro-Afonso FJ, López-Moral M, García-Álvarez Y, García-Morales E, Lázaro-Martínez JL. Is the Combination of Plain X-ray and Probe-to-Bone Test Useful for Diagnosing Diabetic Foot Osteomyelitis? A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:5369. [PMID: 37629412 PMCID: PMC10455253 DOI: 10.3390/jcm12165369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/08/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023] Open
Abstract
A systematic review and meta-analysis was conducted to assess the diagnostic accuracy of the combination of plain X-ray and probe-to-bone (PTB) test for diagnosing diabetic foot osteomyelitis (DFO). This systematic review has been registered in PROSPERO (a prospective international register of systematic reviews; identification code CRD42023436757). A literature search was conducted for each test separately along with a third search for their combination. A total of 18 articles were found and divided into three groups for separate analysis and comparison. All selected studies were evaluated using STROBE guidelines to assess the quality of reporting for observational studies. Meta-DiSc software was used to analyze the collected data. Concerning the diagnostic accuracy variables for each case, the pooled sensitivity (SEN) was higher for the combination of PTB and plain X-ray [0.94 (PTB + X-ray) vs. 0.91 (PTB) vs. 0.76 (X-ray)], as was the diagnostic odds ratio (DOR) (82.212 (PTB + X-ray) vs. 57.444 (PTB) vs. 4.897 (X-ray)). The specificity (SPE) and positive likelihood ratio (LR+) were equally satisfactory for the diagnostic combination but somewhat lower than for PTB alone (SPE: 0.83 (PTB + X-ray) vs. 0.86 (PTB) vs. 0.76 (X-ray); LR+: 5.684 (PTB + X-ray) vs. 6.344 (PTB) vs. 1.969 (X-ray)). The combination of PTB and plain X-ray showed high diagnostic accuracy comparable to that of MRI and histopathology diagnosis (the gold standard), so it could be considered useful for the diagnosis of DFO. In addition, this diagnostic combination is accessible and inexpensive but requires training and experience to correctly interpret the results. Therefore, recommendations for this technique should be included in the context of specialized units with a high prevalence of DFO.
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Affiliation(s)
| | - Francisco Javier Álvaro-Afonso
- Diabetic Foot Unit, Clínica Universitaria de Podología, Facultad de Enfermería, Fisioterapia and Podología, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain; (M.d.M.C.-W.); (M.L.-M.); (Y.G.-Á.); (E.G.-M.); (J.L.L.-M.)
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Systematic review: investigating the added diagnostic value of gadolinium contrast agents for osteomyelitis in the appendicular skeleton. Skeletal Radiol 2022; 51:1285-1296. [PMID: 34643771 DOI: 10.1007/s00256-021-03915-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 09/13/2021] [Accepted: 09/17/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Osteomyelitis is an infection of the bone marrow. MRI with gadolinium-based contrast is frequently performed for cases of suspected osteomyelitis. The objective of this systematic review is to examine the diagnostic accuracy of contrast-enhanced vs non-contrast-enhanced MRI for osteomyelitis in the appendicular skeleton. MATERIALS AND METHODS We conducted a systematic review of MRI in the diagnosis of osteomyelitis by searching MEDLINE and EMBASE from January 2000 to March 2020. There were 21 studies that met the inclusion criteria for the systematic review for a total of 1095 patients. Analytic methods were based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Evidence was evaluated using the STARD criteria for evaluation of completeness and transparency of reporting. RESULTS For diagnosing osteomyelitis in the appendicular skeleton, MRI with gadolinium-based contrast has 89% sensitivity (95% CI, 86-92%), 79% specificity (95% CI, 75-83%), and 90% overall diagnostic accuracy ([SE] = 0.03). For diagnosing osteomyelitis in the appendicular skeleton, MRI without gadolinium-based contrast has a 92% sensitivity (95% CI, 87-96%), 89% specificity (95% CI, 84-93%), and 96% overall diagnostic accuracy ([SE] = 0.03). The median score of included studies was 85% utilizing the STARD criteria with excellent interobserver agreement of 83.4%. Limitations included small sample size of studies, with retrospective designs. CONCLUSION No evidence was found to suggest an added diagnostic value of gadolinium contrast for the diagnosis of osteomyelitis in the appendicular skeleton. For routine cases of suspected non-spinal osteomyelitis, non-contrast MRI of the area of interest is the next most appropriate study after radiographs.
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Llewellyn A, Jones-Diette J, Kraft J, Holton C, Harden M, Simmonds M. Imaging tests for the detection of osteomyelitis: a systematic review. Health Technol Assess 2020; 23:1-128. [PMID: 31670644 DOI: 10.3310/hta23610] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Osteomyelitis is an infection of the bone. Medical imaging tests, such as radiography, ultrasound, magnetic resonance imaging (MRI), single-photon emission computed tomography (SPECT) and positron emission tomography (PET), are often used to diagnose osteomyelitis. OBJECTIVES To systematically review the evidence on the diagnostic accuracy, inter-rater reliability and implementation of imaging tests to diagnose osteomyelitis. DATA SOURCES We conducted a systematic review of imaging tests to diagnose osteomyelitis. We searched MEDLINE and other databases from inception to July 2018. REVIEW METHODS Risk of bias was assessed with QUADAS-2 [quality assessment of diagnostic accuracy studies (version 2)]. Diagnostic accuracy was assessed using bivariate regression models. Imaging tests were compared. Subgroup analyses were performed based on the location and nature of the suspected osteomyelitis. Studies of children, inter-rater reliability and implementation outcomes were synthesised narratively. RESULTS Eighty-one studies were included (diagnostic accuracy: 77 studies; inter-rater reliability: 11 studies; implementation: one study; some studies were included in two reviews). One-quarter of diagnostic accuracy studies were rated as being at a high risk of bias. In adults, MRI had high diagnostic accuracy [95.6% sensitivity, 95% confidence interval (CI) 92.4% to 97.5%; 80.7% specificity, 95% CI 70.8% to 87.8%]. PET also had high accuracy (85.1% sensitivity, 95% CI 71.5% to 92.9%; 92.8% specificity, 95% CI 83.0% to 97.1%), as did SPECT (95.1% sensitivity, 95% CI 87.8% to 98.1%; 82.0% specificity, 95% CI 61.5% to 92.8%). There was similar diagnostic performance with MRI, PET and SPECT. Scintigraphy (83.6% sensitivity, 95% CI 71.8% to 91.1%; 70.6% specificity, 57.7% to 80.8%), computed tomography (69.7% sensitivity, 95% CI 40.1% to 88.7%; 90.2% specificity, 95% CI 57.6% to 98.4%) and radiography (70.4% sensitivity, 95% CI 61.6% to 77.8%; 81.5% specificity, 95% CI 69.6% to 89.5%) all had generally inferior diagnostic accuracy. Technetium-99m hexamethylpropyleneamine oxime white blood cell scintigraphy (87.3% sensitivity, 95% CI 75.1% to 94.0%; 94.7% specificity, 95% CI 84.9% to 98.3%) had higher diagnostic accuracy, similar to that of PET or MRI. There was no evidence that diagnostic accuracy varied by scan location or cause of osteomyelitis, although data on many scan locations were limited. Diagnostic accuracy in diabetic foot patients was similar to the overall results. Only three studies in children were identified; results were too limited to draw any conclusions. Eleven studies evaluated inter-rater reliability. MRI had acceptable inter-rater reliability. We found only one study on test implementation and no evidence on patient preferences or cost-effectiveness of imaging tests for osteomyelitis. LIMITATIONS Most studies included < 50 participants and were poorly reported. There was limited evidence for children, ultrasonography and on clinical factors other than diagnostic accuracy. CONCLUSIONS Osteomyelitis is reliably diagnosed by MRI, PET and SPECT. No clear reason to prefer one test over the other in terms of diagnostic accuracy was identified. The wider availability of MRI machines, and the fact that MRI does not expose patients to harmful ionising radiation, may mean that MRI is preferable in most cases. Diagnostic accuracy does not appear to vary with the potential cause of osteomyelitis or with the body part scanned. Considerable uncertainty remains over the diagnostic accuracy of imaging tests in children. Studies of diagnostic accuracy in children, particularly using MRI and ultrasound, are needed. STUDY REGISTRATION This study is registered as PROSPERO CRD42017068511. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 61. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Alexis Llewellyn
- Centre for Reviews and Dissemination, University of York, York, UK
| | | | | | | | - Melissa Harden
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Mark Simmonds
- Centre for Reviews and Dissemination, University of York, York, UK
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Imaging for detection of osteomyelitis in people with diabetic foot ulcers: A systematic review and meta-analysis. Eur J Radiol 2020; 131:109215. [PMID: 32862106 DOI: 10.1016/j.ejrad.2020.109215] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/09/2020] [Accepted: 08/08/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Osteomyelitis is an infection of the bone which can occur in people with diabetic foot ulcers. It can be diagnosed using X-rays, ultrasound, scintigraphy, magnetic resonance imaging (MRI), single photon emission computed tomography (SPECT) and positron emission tomography (PET). OBJECTIVES To review the evidence on the diagnostic accuracy of imaging tests to diagnose osteomyelitis in people with diabetic foot ulcers. METHODS We conducted a systematic review and meta-analysis. MEDLINE, EMBASE and other databases were searched to July 2018. Risk of bias was evaluated. Diagnostic accuracy was estimated using bivariate meta-analyses. RESULTS 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. CONCLUSIONS MRI and PET both reliably diagnose osteomyelitis in diabetic foot ulcer patients. SPECT may also have good diagnostic accuracy, although evidence is limited. This review confirms most current guidelines, showing that MRI may be the preferable test in most cases, given its wider availability and the lack of potentially harmful ionising radiation.
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Senneville EM, Lipsky BA, van Asten SAV, Peters EJ. Diagnosing diabetic foot osteomyelitis. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3250. [PMID: 31950555 DOI: 10.1002/dmrr.3250] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 11/20/2019] [Indexed: 01/21/2023]
Abstract
Bone involvement during an infection of the diabetic foot represents a serious complication associated with a high risk of amputation, prolonged antibiotic treatment and hospitalization. Diabetic foot osteomyelitis (DFOs) require a multidisciplinary approach given the usual complexity of these situations. DFO should be suspected in most cases especially in the most severe forms of soft tissue diabetic foot infections (DFIs) where the prevalence of bone infection may be up to 60%. Suspicion is based on clinical signs in particular a positive probe-to-bone (PTB) test, elevated inflammatory biomarkers especially erythrocyte sedimentation rate and abnormal imaging assessment using plain X-ray as a first-line choice. The combination of PTB test with plain X-ray has proven effective in the diagnosis of DFO. The confirmation (definite) diagnosis of DFO is based on the results of a bone sample examination obtained by either surgical or percutaneous biopsy. Sophisticated imaging examinations such as Magnetic Resonance Imaging (MRI) and nuclear imaging techniques are useful where doubt persists after first-line imaging assessment. These techniques may also help localize the bone infection site and increase the diagnostic performance of percutaneous bone biopsy. The quality of the microbiological documentation of DFO is likely to improve the adequacy of the antimicrobial therapy especially when medical (ie, no surgical resection of the infected bone tissues) is considered. The use of new (molecular) techniques for the identification of the bone pathogens have not yet proven superiority on classic cultural techniques for the management of such patients.
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Affiliation(s)
| | | | | | - Edgar J Peters
- VU University Medical Centre, Amsterdam, The Netherlands
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Senneville É, Lipsky BA, Abbas ZG, Aragón-Sánchez J, Diggle M, Embil JM, Kono S, Lavery LA, Malone M, van Asten SA, Urbančič-Rovan V, Peters EJG. Diagnosis of infection in the foot in diabetes: a systematic review. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3281. [PMID: 32176440 DOI: 10.1002/dmrr.3281] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/01/2019] [Accepted: 09/19/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Securing an early accurate diagnosis of diabetic foot infections and assessment of their severity are of paramount importance since these infections can cause great morbidity and potentially mortality and present formidable challenges in surgical and antimicrobial treatment. METHODS In June 2018, we searched the literature using PuEbMed and EMBASE for published studies on the diagnosis of diabetic foot infection. On the basis of predetermined criteria, we reviewed prospective controlled, as well as noncontrolled, studies in any language, seeking translations for those not in English. We then developed evidence statements on the basis of the included papers. RESULTS From the 4242 records screened, we selected 35 papers that met our inclusion criteria. The quality of all but one of the evidence statements was low because of the weak methodology of nearly all of the studies. The available data suggest that diagnosing diabetic foot infections on the basis of clinical signs and symptoms and classified according to the International Working Group of the Diabetic Foot scheme correlates with the patient's likelihood of ulcer healing, of lower extremity amputation, and risk of death. Elevated levels of selected serum inflammatory markers are supportive, but not diagnostic, of soft tissue or bone infection. In patients with suspected diabetic foot osteomyelitis, both a positive probe-to-bone test and an elevated erythrocyte sedimentation rate are strongly associated with its presence. Culturing tissue samples of soft tissues or bone, when care is taken to avoid contamination, provides more accurate microbiological information than culturing superficial (swab) samples. Plain X-ray remains the first-line imaging examination when there is suspicion of diabetic foot osteomyelitis, but advanced imaging methods help in cases when either the diagnosis or the localization of infection is uncertain. CONCLUSION The results of this first reported systematic review on the diagnosis of diabetic foot infections provide some guidance for clinicians, but there is a need for more prospective controlled studies of high quality.
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Affiliation(s)
- Éric Senneville
- Gustave Dron Hospital, Tourcoing, France
- Lille University, France
| | | | - Zulfiqarali G Abbas
- Abbas Medical Centre, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Mathew Diggle
- Alberta Public Laboratories, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - John M Embil
- University of Manitoba, Winnipeg, Manitoba, Canada
| | - Shigeo Kono
- WHO-Collaborating Centre for Diabetes, National Hospital Organization Kyoto Medical Centre, Kyoto, Japan
| | - Lawrence A Lavery
- University of Texas Southwestern Medical Center and Parkland Hospital, Dallas, TX
| | - Matthew Malone
- School of Medicine, Infectious Diseases and Microbiology, Western Sydney University, Sydney, New South Wales, Australia
- South West Sydney Local Health District, Sydney, New South Wales, Australia
| | - Suzanne A van Asten
- Faculty of Medicine, University Medical Centre, University of Ljubljana, Ljubljana, Slovenia
| | - Vilma Urbančič-Rovan
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Edgar J G Peters
- Department of Internal Medicine, Section of Infectious Diseases, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Infection and Immunity Institute, Amsterdam, The Netherlands
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Lam K, van Asten SAV, Nguyen T, La Fontaine J, Lavery LA. Diagnostic Accuracy of Probe to Bone to Detect Osteomyelitis in the Diabetic Foot: A Systematic Review. Clin Infect Dis 2016; 63:944-8. [DOI: 10.1093/cid/ciw445] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 06/03/2016] [Indexed: 11/14/2022] Open
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