Serial X-Ray Radiography for the Diagnosis of Osteomyelitis: A Review of Diagnostic Accuracy, Clinical Utility, Cost-Effectiveness, and Guidelines

Key Message

This review included three evidence-based guidelines for diagnosis of peripheral bone infection, diabetic foot infection, and native vertebral osteomyelitis in adults. No studies on the diagnostic accuracy, clinical utility and cost-effectiveness of serial X-ray radiography for diagnosis of osteomyelitis were identified.

All three guidelines were considered to be of good methodological quality. Based on moderate to low quality evidence, the guidelines had recommendations for diagnosis of osteomyelitis regarding medical examination, laboratory tests, bone biopsy and bone culture, and imaging tests. Bone biopsy and bone culture are considered as the reference standard to confirm the infection and identify the causative microorganism. Although magnetic resonance imaging, positron emission tomography and single-photon emission computed tomography were found to have higher diagnostic performance than radiography, it is recommended that conventional X-ray radiography should be the first imaging modality for detection of osteomyelitis, particularly for suspected peripheral bone infection or for osteomyelitis in diabetic foot infection. With suspected native vertebral osteomyelitis, spine magnetic resonance imaging, when feasible, is recommended as first imaging of choice. Subsequent imaging tests may be considered depending on the extent of the investigation, the availability of the imaging modalities, the level of diagnostic accuracy required, the complexity of the disease, and any contraindications.

There is a need for studies examining the diagnostic accuracy, clinical utility and cost-effectiveness of serial X-ray radiography for detection of osteomyelitis in adults.