Plain Radiography for Diagnosing and Monitoring Foot Osteomyelitis in Persons With Diabetes: Accuracy, Limitations...

Osteomyelitis of the feet is common in persons living with diabetes due to peripheral artery disease, peripheral neuropathy, and increased susceptibility to infection. Although plain radiography is a low-cost and widely available diagnostic tool, its diagnostic performance is limited. Serial radiography may improve the accuracy and clinical utility. This systematic review studies the diagnostic accuracy, limitations, and clinical utility of singular versus serial plain radiography for diagnosing osteomyelitis in the foot in persons with diabetes at diagnosis and follow-up. We conducted PubMed and Embase searches for articles on the diagnostic performance of serial plain radiography for osteomyelitis of the foot in patients with diabetes. Multiple z-tests were used to compare the performance of singular and serial radiographs. Fourteen studies were included, with only one providing original data on serial radiography. The sensitivity of singular radiography ranged from 22% to 93%, and specificity ranged from 22% to 94%. Serial radiography had a sensitivity of 89% and a specificity of 38%. Of the 13 studies, serial radiography outperformed singular radiography in terms of sensitivity in three reports but failed to outperform singular radiography on specificity in any of the reports. The initial examination indicated little advantage of serial radiography over singular radiography for the diagnosis of diabetic foot osteomyelitis. However, a significant exclusion bias exists due to the lack of research in this area. Further research is warranted to clarify the clinical utility of serial radiography.