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Gillian Lieberman, MD
March, 2011
Osteomyelitis:
The Role of Radiography in Diagnosis
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Spencer McClelland, HMS III
Gillian Lieberman, MD
Our Patient:
Foot X-ray
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Spencer McClelland, HMS III
Gillian Lieberman, MD
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Spencer McClelland, HMS III
Gillian Lieberman, MD
Osteomyelitis: Overview
• Infection of bone
• Can occur by:
• Contiguous spreading (i.e. from an ulcer)
• Hematogenous seeding (i.e. in bacteremia)
• Direct inoculation (i.e. from trauma)
• Organisms responsible can be
monomicrobial or polymicrobial
• Hematogenous is usually monomicrobial
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Jeffcoate, WJ, et al. Clin Infec Dis. 2004
Spencer McClelland, HMS III
Gillian Lieberman, MD
Osteomyelitis: Diagnosis
• Diagnosis of osteomyelitis requires one of the
following:
• Isolation of bacteria from a bone biopsy sample
obtained via sterile technique, together with
histologic findings of inflammation and osteonecrosis
• Positive radiologic finding beneath a foot ulcer
• Positive radiologic finding with positive blood
cultures
• Probing to bone in a diabetic foot ulcer
• Diabetic foot ulcer greater than 2 X 2 cm
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Jeffcoate, WJ, et al. Clin Infec Dis. 2004; Grayson, ML, et al, JAMA, 1995
Spencer McClelland, HMS III
Gillian Lieberman, MD
Osteomyelitis: Diagnosis
• Diagnosis of osteomyelitis requires one of the
following:
• Isolation of bacteria from a bone biopsy sample
obtained via sterile technique, together with
histologic findings of inflammation and osteonecrosis
• Positive radiologic finding beneath a foot ulcer
• Positive radiologic finding with positive blood
cultures
• Probing to bone in a diabetic foot ulcer
• Diabetic foot ulcer greater than 2 X 2 cm
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Jeffcoate, WJ, et al. Clin Infec Dis. 2004; Grayson, ML, et al, JAMA, 1995
Spencer McClelland, HMS III
Gillian Lieberman, MD
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Spencer McClelland, HMS III
Gillian Lieberman, MD
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Spencer McClelland, HMS III
Gillian Lieberman, MD
Our Patient:
Foot X-ray
• Marked bone lysis of the
distal first metatarsal, first
proximal phalanx, and first
distal phalanx
• Mild cortical lucency and
sclerosis of the medial aspect
of the distal second
metatarsal
• Marked soft tissue swelling
along the medial foot and
surrounding the first toe
joints
• Solid periosteal reaction of
the first metatarsal
Source: BIDMC PACS
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Spencer McClelland, HMS III
Gillian Lieberman, MD
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Spencer McClelland, HMS III
Gillian Lieberman, MD
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Spencer McClelland, HMS III
Gillian Lieberman, MD
Osteomyelitis: CT Findings
• Superior spatial resolution compared to MRI,
but lower sensitivity and specificity
• Useful when MRI is contraindicated or
unavailable, or for surgical planning
• Bone findings: cortical breakdown, trabecular
changes, periosteal reaction, intraosseous gas
• Soft tissue findings: sinus tract projection
• Particularly good for showing sequestra and
involucra (discussed later)
Pineda, C, et al. Infect Dis Clin North Am. 2006; Sammak, B, et al, Eur Radiol, 1999 18
Spencer McClelland, HMS III
Gillian Lieberman, MD
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Spencer McClelland, HMS III
Gillian Lieberman, MD
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Spencer McClelland, HMS III
Gillian Lieberman, MD
Osteomyelitis
Nuclear Medicine: Bone Scan Findings
• Three-phase bone scan with radiolabeled marker like
Technetium-99
• Flow phase: immediately after injection
• Shows areas of increased blood flow, i.e. inflammation
• Pooling phase: 15 minutes after injection
• Shows areas of vascular permeability
• Delayed phase: 4 hours after injection
• Shows areas of retained uptake, most specific for osteomyelitis
• Sensitivity/Specificity
• If positive in three phases, sensitivity 73-100%
• Metanalysis: sensitivity 61%, specificity 25%
• Sensitivity decreases with coexisting conditions, like trauma,
surgery, orthopedic hardware, diabetes
Pineda, C, et al. Infect Dis Clin North Am. 2006 23
Spencer McClelland, HMS III
Gillian Lieberman, MD
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Spencer McClelland, HMS III
Gillian Lieberman, MD
Companion Patient #3
Foot Bone Scan: Flow Phase
R L
Courtesy of Dr. Kevin Donohoe
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Spencer McClelland, HMS III
Gillian Lieberman, MD
Companion Patient #3
Foot Bone Scan: Flow Phase
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Courtesy of Dr. Kevin Donohoe
Spencer McClelland, HMS III
Gillian Lieberman, MD
Companion Patient #3
Foot Bone Scan: Flow Phase
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Courtesy of Dr. Kevin Donohoe
Spencer McClelland, HMS III
Gillian Lieberman, MD
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Spencer McClelland, HMS III
Gillian Lieberman, MD
Osteomyelitis
Nuclear Medicine Findings: Gallium
Scan
• Uses radiolabeled gallium, which likely attaches to
acute phase reactant proteins
• Good sensitivity (25-80%)
• More specific than three-phase bone scan (67%)
• False positives due to fracture and neoplasm
• Scan occurs 24 hours after injection, so only useful
in the clinically stable patient
Osteomyelitis
Nuclear Medicine: Other Studies
• Tagged WBCs
• Radiolabeled antibiotics
• Labeled immunoglobulins
• Streptavidin
• 111In-biotin
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Spencer McClelland, HMS III
Gillian Lieberman, MD
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Spencer McClelland, HMS III
Gillian Lieberman, MD
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Spencer McClelland, HMS III
Gillian Lieberman, MD
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Spencer McClelland, HMS III
Gillian Lieberman, MD
An Algorithm:
Putting It All Together
Take-Home Points
• Osteomyelitis is an infection of bone
• The gold standard for diagnosis is a sterile surgical biopsy,
but imaging can play a great role in the absence of that
• X-ray is the first line for imaging, as it is fast and
inexpensive, but its sensitivity is only fair, since it takes
weeks for changes to become apparent
• MRI is the best modality, both in terms of sensitivity and
specificity, and in terms of its ability to detect changes
early on
• Nuclear medicine studies have good sensitivity, but mixed
specificity, as many other conditions can cause increased
focal uptake of radiolabeled markers
• Many algorithms exist for how to diagnose osteomyelitis
in different clinical scenarios… follow them!
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Student Name, year
Gillian Lieberman, MD
Acknowledgments
• Dr. Jim Wu
• Dr. Kevin Donohoe
• Dr. David Glazier
• Dr. Mai-Lan Ho
• Dr. Monica Agarwal
• Dr. Gillian Lieberman
• Emily Hanson
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Student Name, year
Gillian Lieberman, MD
References
• Grayson, ML, et al. Probing to bone in infected pedal ulcers. A clinical sign of
underlying osteomyelitis in diabetic patients. JAMA. 1995 Mar 1;273(9):721-3.
• Jeffcoate, WJ, et al. Controversies in Diagnosis and Management of
Osteomyelitis of the Foot in Diabetes. Clin Infect Dis. (2004) 39 (Supplement
2): S115-S122.
• Lipsky, BA, et al. Diagnosis and Treatment of Diabetic Foot Infections. Clin
Infect Dis. (2004) 39 (7): 885-910.
• Mader JT, et al. Update on the diagnosis and management of osteomyelitis.
Clin Podiatr Med Surg. 1996;13(4):701-24
• Pineda, C, et al. Imaging of Osteomyelitis: Current Concepts. Infect Dis Clin
North Am. 2006 Dec;20(4):789-825.
• Sammak, B, et al. Osteomyelitis: a review of currently used imaging
techniques. Eur Radiol. 9,894-900 (1999).
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Student Name, year
Gillian Lieberman, MD
THANK YOU!
And Happy Belated St. Patty’s Day,
from Brooklyn the Irish Croco-Dog!
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