Background: A variety of diagnostic imaging techniques is available
for excluding or confirming chronic osteomyelitis. Until now, an
evidence-based algorithmic model for choosing the most suitable imaging
technique has been lacking. The objective of this study was to determine the
accuracy of current imaging modalities in the diagnosis of chronic
osteomyelitis.
Methods: A systematic review and meta-analysis of the literature was
conducted with a comprehensive search of the MEDLINE, EMBASE, and Current
Contents databases to identify clinical studies on chronic osteomyelitis that
evaluated diagnostic imaging modalities. The value of each imaging technique
was studied by determining its sensitivity and specificity compared with the
results of histological analysis, findings on culture, and clinical follow-up
of more than six months.
Results: A total of twenty-three clinical studies in which the
accuracy was described for radiography (two studies), magnetic resonance
imaging (five), computed tomography (one), bone scintigraphy (seven),
leukocyte scintigraphy (thirteen), gallium scintigraphy (one), combined bone
and leukocyte scintigraphy (six), combined bone and gallium scintigraphy
(three), and fluorodeoxyglucose positron emission tomography (four) were
included in the review. No meta-analysis was performed with respect to
computed tomography, gallium scintigraphy, and radiography. Pooled sensitivity
demonstrated that fluorodeoxyglucose positron emission tomography was the most
sensitive technique, with a sensitivity of 96% (95% confidence interval, 88%
to 99%) compared with 82% (95% confidence interval, 70% to 89%) for bone
scintigraphy, 61% (95% confidence interval, 43% to 76%) for leukocyte
scintigraphy, 78% (95% confidence interval, 72% to 83%) for combined bone and
leukocyte scintigraphy, and 84% (95% confidence interval, 69% to 92%) for
magnetic resonance imaging. Pooled specificity demonstrated that bone
scintigraphy had the lowest specificity, with a specificity of 25% (95%
confidence interval, 16% to 36%) compared with 60% (95% confidence interval,
38% to 78%) for magnetic resonance imaging, 77% (95% confidence interval, 63%
to 87%) for leukocyte scintigraphy, 84% (95% confidence interval, 75% to 90%)
for combined bone and leukocyte scintigraphy, and 91% (95% confidence
interval, 81% to 95%) for fluorodeoxyglucose positron emission tomography. The
sensitivity of leukocyte scintigraphy in detecting chronic osteomyelitis in
the peripheral skeleton was 84% (95% confidence interval, 72% to 91%) compared
with 21% (95% confidence interval, 11% to 38%) for its detection of chronic
osteomyelitis in the axial skeleton. The specificity of leukocyte scintigraphy
in the axial skeleton was 60% (95% confidence interval, 39% to 78%) compared
with 80% (95% confidence interval, 61% to 91%) for the peripheral
skeleton.
Conclusions: Fluorodeoxyglucose positron emission tomography has the
highest diagnostic accuracy for confirming or excluding the diagnosis of
chronic osteomyelitis. Leukocyte scintigraphy has an appropriate diagnostic
accuracy in the peripheral skeleton, but fluorodeoxyglucose positron emission
tomography is superior for detecting chronic osteomyelitis in the axial
skeleton.
Level of Evidence: Diagnostic Level III. See Instructions
to Authors for a complete description of levels of evidence.