Dr. Judge concurs that a chronic wound that probes to bone is particularly concerning as it may be a harbinger of impending osteomyelitis. When there is a negative X-ray in the presence of an open wound that probes to bone, Dr. Ford says either the bone is not infected or the bone is infected but just has not shown up on X-rays yet.
In regard to the initial radiolucency, Dr. Zgonis says underlying osteomyelitis requires five to seven days to manifest radiographically. He adds that it takes between 10 to 14 days for the first signs of sequestrum and involucrum to be noticeable.
Dr. Zgonis says one can use radiographs to determine the presence of soft tissue swelling, ulcer tracking, gas in the tissues, cortical irregularity and focal demineralization.2 When it comes to an early presentation of osteomyelitis, Dr. Zgonis notes that initial radiographs are usually abnormal in less than 5 percent of the patients. Yet by the third or fourth week, 90 percent of the patients will demonstrate clinical changes consistent with osteomyelitis.3
In the particular clinical scenario raised above, Dr. Judge says the lack of radiographic changes in bone would make her suspect an indolent soft tissue infection. When it comes to determining whether there is a microbial cause for treatment failure, Dr. Judge proceeds to use nuclear medicine leukocyte imaging (NMLI).
She says NMLI results will reveal one of three things. The results may indicate an infection and provide specifics on the location and extent of the infection. The results can identify when no infection exists and accordingly support the continued use of conservative care including second opinions. One can also use NMLI to diagnose a coincident inflammatory process similar to what one might see in the presence of hypertrophic bone or malignancy.
In addition to identifying and localizing an infectious process, Dr. Judge says using NMLI can help one delineate between bone and soft tissue infection.
Usually, if there is infected soft tissue and one can probe to bone, one is dealing with osteomyelitis, according to Dr. Ford. If the wound is not infected, Dr. Ford emphasizes obtaining a biopsy and culture of the exposed bone to determine whether the patient has osteomyelitis, and treating the patient accordingly based upon the results.
Q: What role do nuclear medicine studies play in the treatment of diabetic wounds?
A: Dr. Ford says the results can be “confusing due to the suspicion of false positives and false negatives.” He rarely finds nuclear medicine studies helpful in managing wounds. When there is exposed bone through a chronic wound on the plantar aspect of the foot, Dr. Ford points out that bony turnover is likely and a response of inflammatory cells will make it “extremely difficult” to distinguish between infection and inflammation.
He notes that he tends to rely more upon clinical findings, lab and microbiology studies, and standard X-rays. However, when there is no exposed bone in the wound, Dr. Ford says he will use nuclear medicine imaging more as the specificity for osteomyelitis would be greater.
Dr. Zgonis does order scintigraphy to confirm osteomyelitis as well as to determine its extent. Technetium-99 bone scans can be positive for numerous conditions including but not limited to osteomyelitis, Charcot neuropathy, fractures, systemic arthritides, bone tumors and postsurgical changes, according to Dr. Zgonis. While these scans are not “very specific,” he notes they are “quite sensitive” in diagnosing osteomyelitis. Dr. Zgonis adds that the literature supports the use of more specific tests including but not limited to Gallium-67, Indium-111, Tec-99 HMPAO and sulfur colloid scans in confirming osteomyelitis.4,5