Unsuspected osteomyelitis in diabetic foot ulcers. Diagnosis and ³
monitoring by leukocyte scanning with indium in 111 oxyquinoline; Newman LG. Waller J. Palestro CJ. Schwartz M. Klein MJ. Hermann G. Harrington E. Harrington M. Roman SH. Stagnaro-Green A. Comment in: JAMA 1992 Jan 22-29;267(4):510-1 JAMA. 266(9):1246-51, 1991 Sep 4. OBJECTIVE. The prevalence of osteomyelitis in diabetic foot ulcers is unknown. Early diagnosis of this infection is critical, as prompt antibiotic treatment decreases the rate of amputation. We therefore assessed the prevalence of osteomyelitis in 35 diabetic patients with 41 foot ulcers. We compared results of roentgenograms, leukocyte scans with indium In 111 oxyquinoline, and bone scans with the diagnostic criterion standards of bone histologic and culture findings. Leukocyte scans were * repeated at 2- to 3-week intervals during antibiotic treatment. DESIGN. Cohort study. SETTING. Institutional and private, ambulatory and hospitalized patients. PATIENTS. Consecutive sample of 54 diabetic patients. Thirty-five patients with 41 foot ulcers were included. RESULTS. As determined by bone biopsy and culture, osteomyelitis was found to underlie 28 (68%) of 41 diabetic foot ulcers. Only nine (32%) of the 28 Á In patients with osteomyelitis, the leukocyte scan image intensity  decreased by 16 to 34 days of antibiotic treatment and normalized by 36 to 54 days. CONCLUSION. The majority of diabetic foot ulcers have an underlying osteomyelitis that is clinically unsuspected. Leukocyte scans are highly sensitive for diagnosing osteomyelitis in diabetic foot ulcers and may be useful for monitoring the efficacy of antibiotic treatment. We recommend that diabetic patients with foot ulcers that expose bone should be treated for osteomyelitis. Diabetic patients with foot ulcers that do not expose bone should undergo leukocyte scanning, which eliminates the risk of bone biopsy in diagnosing osteomyelitis and allows for the diagnosis and treatment of this well-known but often silent precursor of lower extremity amputation. *
Original Text by Clifford R. Wheeless, III, MD.
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