Are We Misdiagnosing Diabetic Foot Osteomyelitis? Is the Gold Standard Gold?

Lawrence A Lavery, P. Andrew Crisologo, Javier La Fontaine, Kavitha Bhavan, Orhan K Oz, Katie Ellen Davis

Research output: Contribution to journalArticle

Abstract

To compare the incidence of osteomyelitis based on different operational definitions using the gold standard of bone biopsy, we prospectively enrolled 35 consecutive patients who met the criteria of ≥21 years of age and a moderate or severe infection based on the Infectious Diseases Society of America classification. Bone samples were obtained from all patients by percutaneous bone biopsy or intraoperative culture if the patient required surgery. Bone samples were analyzed for conventional culture, histology, and 16S ribosomal RNA genetic sequencing. We evaluated 5 definitions for osteomyelitis: 1) traditional culture, 2) histology, 3) genetic sequencing, 4) traditional culture and histology, and 5) genetic sequencing and histology. There was variability in the incidence of osteomyelitis based on the diagnostic criteria. Traditional cultures identified more cases of osteomyelitis than histology (68.6% versus 45.7%, p =.06, odds ratio [OR] 2.59, 95% confidence interval [CI] 0.98 to 6.87), but the difference was not significant. In every case that histology reported osteomyelitis, bone culture was positive using traditional culture or genetic sequencing. The 16S ribosomal RNA testing identified significantly more cases of osteomyelitis compared with histology (82.9% versus 45.7%, p =.002, OR 5.74, 95% CI 1.91 to 17.28) and compared with traditional cultures but not significantly (82.9% versus 68.6%, p =.17, OR 2.22, 95% CI 0.71 to 6.87). When both histology and traditional culture (68.6%) or histology and genetic sequencing cultures (82.9%) were used to define osteomyelitis, the incidence of osteomyelitis did not change. There is variability in the incidence of osteomyelitis based on how the gold standard of bone biopsy is defined in diabetic foot infections.

Original languageEnglish (US)
Pages (from-to)713-716
Number of pages4
JournalJournal of Foot and Ankle Surgery
Volume58
Issue number4
DOIs
StatePublished - Jul 1 2019

Fingerprint

Diabetic Foot
Osteomyelitis
Diagnostic Errors
Gold
Histology
Bone and Bones
16S Ribosomal RNA
Odds Ratio
Incidence
Confidence Intervals
Biopsy
RNA Sequence Analysis
Infection

Keywords

  • 2
  • biopsy
  • diabetes
  • diagnosis
  • foot ulcer
  • infection
  • osteomyelitis

ASJC Scopus subject areas

  • Surgery
  • Orthopedics and Sports Medicine

Cite this

Are We Misdiagnosing Diabetic Foot Osteomyelitis? Is the Gold Standard Gold? / Lavery, Lawrence A; Crisologo, P. Andrew; La Fontaine, Javier; Bhavan, Kavitha; Oz, Orhan K; Davis, Katie Ellen.

In: Journal of Foot and Ankle Surgery, Vol. 58, No. 4, 01.07.2019, p. 713-716.

Research output: Contribution to journalArticle

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abstract = "To compare the incidence of osteomyelitis based on different operational definitions using the gold standard of bone biopsy, we prospectively enrolled 35 consecutive patients who met the criteria of ≥21 years of age and a moderate or severe infection based on the Infectious Diseases Society of America classification. Bone samples were obtained from all patients by percutaneous bone biopsy or intraoperative culture if the patient required surgery. Bone samples were analyzed for conventional culture, histology, and 16S ribosomal RNA genetic sequencing. We evaluated 5 definitions for osteomyelitis: 1) traditional culture, 2) histology, 3) genetic sequencing, 4) traditional culture and histology, and 5) genetic sequencing and histology. There was variability in the incidence of osteomyelitis based on the diagnostic criteria. Traditional cultures identified more cases of osteomyelitis than histology (68.6{\%} versus 45.7{\%}, p =.06, odds ratio [OR] 2.59, 95{\%} confidence interval [CI] 0.98 to 6.87), but the difference was not significant. In every case that histology reported osteomyelitis, bone culture was positive using traditional culture or genetic sequencing. The 16S ribosomal RNA testing identified significantly more cases of osteomyelitis compared with histology (82.9{\%} versus 45.7{\%}, p =.002, OR 5.74, 95{\%} CI 1.91 to 17.28) and compared with traditional cultures but not significantly (82.9{\%} versus 68.6{\%}, p =.17, OR 2.22, 95{\%} CI 0.71 to 6.87). When both histology and traditional culture (68.6{\%}) or histology and genetic sequencing cultures (82.9{\%}) were used to define osteomyelitis, the incidence of osteomyelitis did not change. There is variability in the incidence of osteomyelitis based on how the gold standard of bone biopsy is defined in diabetic foot infections.",
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