Abstract
Purpose:To determine the diagnostic performance of technetium bone scanning in the setting of possible osteomyelitis in the foot of a patient who has diabetes or other vasculopathy.
Design:Meta-analysis.
Data identification and study selection:To be eligible for inclusion, a report must have used intravenous technetium-99m methylene diphosphonate or a similar agent in humans over the age of 16 years, must have addressed possible osteomyelitis of the lower extremity with ulcer or soft-tissue inflammation in the setting of diabetes, neuropathy, or vasculopathy, and must have allowed the generation of a two-by-two table. A structured search of the MEDLARS database found 296 possibly eligible reports; ten met all the inclusion criteria.
Data extraction and synthesis:The reported sensitivity and specificity of each report were converted to their logistic transforms and a straight line was fitted by weighted least-squares regression. The line was then back-transformed to yield a summary receiver operating characteristic curve. The false-positive rate of the bone scan is at best in the range of 10 to 20%. This occurs at sensitivities between 70 and 80%. The studies with increased sensitivity also reported sizable increases in the false-positive rate ranging from 20 to over 90%. Even small increases in sensitivity have necessitated large sacrifices in specificity. Seven of the ten studies reported specificities under 70%.
Conclusions:Published data defining the effectiveness of technetium bone scanning for the diagnosis of osteomyelitis in the impaired foot indicate relatively poor performance. In many clinical situations, the specificity of the bone scan will not be high enough to confirm the diagnosis of osteomyelitis.
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References
Ignatov A, Dyankov L, Velichkov L, Pampulov L, Gavrailov M, Andreyev D. Radioisotopic diagnosis of ossa pedis changes in diabetes. Med Radiol (Mosk). 1979;24(6):34–8.
Alazraki N, Dries D, Datz F, Lawrence P, Greenberg E, Taylor A Jr. Value of a 24-hour image (four-phase bone scan) in assessing osteomyelitis in patients with peripheral vascular disease. J Nucl Med. 1985;26:711–7.
Caprioli R, Testa J, Cournoyer RW, Esposito FJ. Prompt diagnosis of suspected osteomyelitis by utilizing percutaneous bone culture. J Foot Surg. 1986;25(4):263–9.
Hetherington VJ. Technetium and combined gallium and technetium scans in the neurotrophic foot. J Am Podiatr Med Assoc. 1982;72(9):458–63.
Keenan AM, Tindel NL, Alavi A. Diagnosis of pedal osteomyelitis in diabetic patients using current scintigraphic techniques. Arch Intern Med. 1989;149:2262–6.
Maurer AH, Millmond SH, Knight LC, et al. Infection in diabetic osteoarthropathy: use of indium-labeled leukocytes for diagnosis. Radiology. 1986;161:221–5.
Park H-M, Wheat LJ, Siddiqui AR, et al. Scintigraphic evaluation of diabetic osteomyelitis: concise communication. J Nucl Med. 1982;23:569–73.
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. 1988;29:1651–5.
Segall GM, Nino-Murcia M, Jacobs T, Chang K. The role of bone scan and radiography in the diagnostic evaluation of suspected pedal osteomyelitis. Clin Nucl Med. 1989;14:255–60.
Seldin DW, Heiken JP, Feldman F, Alderson PO. Effect of soft-tissue pathology on detection of pedal osteomyelitis. J Nucl Med. 1985;26:988–93.
Yuh TC, 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 Am J Roentgenol. 1989;152:795–800.
Moses LE, Littenberg B, Shapiro D, Rabinowitz D. Some data-analytic methods for combining estimates of sensitivity and specificity into a single ROC curve for a diagnostic test. Submitted to Statistics in Medicine, 1990.
Bamberger DM, Daus GP, Gerding DN. Osteomyelitis in the feet of diabetic patients: long-term results, prognostic factors, and the role of antimicrobial and surgical therapy. Am J Med. 1987;83:653–60.
Newman JG, Waller J, Palestro CJ, et al. Unsuspected osteomyelitis in diabetic foot ulcers. JAMA. 1991;266:1246–51.
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Supported by a grant from the John A. Hartford Foundation to the Diagnostic Technology Assessment Consortium. The Consortium includes: Dartmouth-Hitchcock Medical Center: W. Blair Brooks, MD, Terry Hurlbut III, MD, Benjamin Littenberg, MD, Andre Midgette, MD, MPH, David Smith, MD, Harold C. Sox, Jr., MD, and Carole Toselli, MD; Massachusetts General Hospital: Albert Mulley, Jr., MD; Stanford University: Lincoln E. Moses, PhD; University of Pennsylvania: Bruce Kinosian, MD, and J. Sanford Schwartz, MD; University of Rochester Medical Center: Daniel Kido, MD, Alvin I. Mushlin, MD, and Charles E. Phelps, PhD; and University of Washington: Richard Hoffman, MD, Dan Kent, MD, and Eric Larson, MD. Dr. Littenberg is an American College of Physicians George Morris Piersol Teaching and Research Scholar.
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Littenberg, B., Mushlin, A.I. & the Diagnostic Technology Assessment Consortium. Technetium bone scanning in the diagnosis of osteomyelitis. J Gen Intern Med 7, 158–164 (1992). https://doi.org/10.1007/BF02598005
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DOI: https://doi.org/10.1007/BF02598005