What is the next step in management if the probability to bone disease is positive?

From the Guidelines

The next step in management if the probability of bone disease is positive is to obtain plain X-rays of the foot, as this is a crucial initial step in the diagnosis and management of bone disease, especially in cases of suspected osteomyelitis. According to the guidelines provided by 1, plain X-rays should be obtained in all cases of non-superficial diabetic foot infections.

Key Considerations:

• The use of MRI is recommended when an advanced imaging test is needed for diagnosing bone disease, as it provides excellent soft-tissue contrast and can help evaluate the extent of the disease 1.
• In cases where MRI is not available or contraindicated, a white blood cell-labelled radionuclide scan, or possibly single-photon emission computed tomography (CT) and computed tomography (SPECT/CT) or fluorine-18-fluorodeoxyglucose positron emission tomography (PET) scans may be considered 1.
• For patients with suspected chronic osteomyelitis, imaging with radiography and MRI is the first step in the workup, except in the setting of a necrotic and extensive decubitus ulcer, for which surgical debridement and intraoperative cultures are recommended 1.
• The diagnosis of bone disease often requires a combination of clinical evaluation, laboratory tests, and imaging studies, and a multidisciplinary approach may be necessary for optimal management 1.

Management Approach:

• A definite diagnosis of bone infection usually requires positive results on both histological (and optimally microbiological) examinations of an aseptically obtained bone sample 1.
• In cases where the diagnosis is in doubt or determining the causative pathogen's antibiotic susceptibility is crucial, a bone biopsy may be necessary 1.
• The treatment approach should be individualized based on the severity of the disease, the presence of any complications, and the patient's overall health status 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Next Steps in Management

If the probability to bone disease is positive, the next steps in management would involve:

• Confirming the diagnosis through imaging techniques such as:
  • Metastatic bone survey 2
  • Computerized tomography (CT) scanning 2
  • Magnetic resonance imaging (MRI) 2, 3
  • Positron emission tomography (PET) scans 2
• Evaluating the extent of bone disease and assessing for any complications
• Referring the patient to a specialist, such as an oncologist or orthopedic surgeon, for further management

Treatment Options

Treatment options for bone disease may include:

• Bisphosphonate therapy to suppress osteoclastic bone resorption 2
• Kyphoplasty or vertebroplasty to stabilize fractures 2
• Radiation therapy to treat bone lesions 2
• Novel agents to suppress osteoclastic bone resorption 2
• Surgery to treat complications such as osteonecrosis of the jaw 2

Diagnostic Accuracy

The diagnostic accuracy of different imaging techniques for bone disease has been studied, with results showing:

• MRI has high sensitivity and specificity for diagnosing osteomyelitis 3, 4
• CT scans are more sensitive than plain radiographs for detecting small lytic lesions 2
• Bone scintigraphy has high sensitivity but low specificity for diagnosing osteomyelitis 3, 4
• Late x-ray is the most valuable radiologic method in the diagnosis of acute hematogenous osteomyelitis, but bone scintigraphy and MRI are the most valuable tests at the onset of the disease 4