Plain Radiography for Diagnosing and Monitoring Foot Osteomyelitis in Persons With Diabetes: Accuracy, Limitations and Clinical Utility
Summary: This systematic review evaluates the diagnostic performance of plain radiography (singular and serial) for detecting foot osteomyelitis in people with diabetes—a frequent complication driven by peripheral artery disease, neuropathy, and infection susceptibility. Plain X-rays are low-cost and widely available but suffer from poor sensitivity/specificity. Only one of 14 included studies provided original data on serial radiography. Singular radiography showed highly variable performance (sensitivity 22–93%, specificity 22–94%). Serial radiography achieved 89% sensitivity but only 38% specificity. Across reports, serial imaging improved sensitivity in three studies but showed no specificity advantage in any. Overall, serial radiography offers minimal added benefit over a single radiograph for initial diagnosis or monitoring, though significant research gaps and exclusion bias limit conclusions. Calls for further studies to better define clinical utility in diabetic foot osteomyelitis management.
Key Highlights:
- Diagnostic variability: Singular plain radiography sensitivity/specificity highly inconsistent across studies.
- Serial performance: Higher sensitivity (89%) but poor specificity (38%); outperforms single in sensitivity in only a minority of reports.
- Limitations: Low overall accuracy; early changes often invisible on X-ray (requires 10–14 days for visible bone changes); influenced by comorbidities in diabetes.
- Clinical implications: Plain radiography remains first-line due to accessibility/cost but insufficient alone—often requires MRI, bone scan, or probe-to-bone test for confirmation in suspected diabetic foot osteomyelitis.
- Research gap: Sparse data on serial use; exclusion bias suggests understudied area warrants more prospective research for follow-up monitoring value.
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Keywords: diabetic foot osteomyelitis, plain radiography, serial radiography, diagnostic accuracy, diabetic foot infection