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

Osteomyelitis is an inflammation of the bone due to infection caused by bacteria, commonly Staphylococcus aureus. Bacteria can reach the bone through various means including trauma, surgery, the blood stream, extension from an adjacent soft tissue infection, or diabetic foot infection. Osteomyelitis can occur at any age, although the incidence appears to peak at children under the age of five and in adults over 50 years of age. It can be classified as acute or chronic, based on histopathological findings. Factors associated with osteomyelitis include aging, increased prevalence of trauma, and increased prevalence of diabetic foot infection.Early detection of osteomyelitis will likely lead to more favorable outcomes. Diagnosis of osteomyelitis requires a multidisciplinary approach including clinical examination, recognition and assessment of clinical symptoms, laboratory investigations and imaging tests. There are various imaging modalities that have been used in the characterization and differential diagnosis of osteomyelitis, such as plain X-ray radiography, computed tomography (CT), magnetic resonance imaging (MRI), bone scintigraphy, positron emission tomography (PET), single-photon emission computed tomography (SPECT), and ultrasonography., The diagnostic accuracies of these imaging tests for diagnosis of osteomyelitis have been systematically reviewed. Although plain X-ray radiography has lower sensitivity and specificity compared to other imaging tests, the American College of Radiology Appropriateness Criteria and reviews recommend that X-ray should be used as first line imaging modality to differentiate osteomyelitis from other clinical conditions such as bone fractures or bone malignancies.,, Plain X-ray radiography, whether or not with positive or negative results, is usually followed by higher sensitivity and specificity imaging modalities for diagnosis of osteomyelitis. However, in institutions where the availability of more sophisticated imaging modalities is limited, it is unclear if the use of serial X-ray radiography (i.e., initial assessment with X-rays followed by subsequent X-rays in 1 to 3 weeks), could improve diagnostic accuracy for detection of osteomyelitis.The aim of this report is to review the diagnostic accuracy, clinical utility, and cost-effectiveness of serial X-ray radiography in adults with suspected osteomyelitis compared to other diagnostic modalities. This report also aims to identify evidence-based guidelines regarding the use of diagnostic modalities in adults with suspected osteomyelitis.