3
Assessment
Diagnosis of Diabetic Foot Osteomyelitis (DFO)
➤ In patients with a diabetic foot infection (DFI) with an open wound, we
suggest doing a probe to bone (PTB) test to aid in diagnosis (2C).
➤ In all patients presenting with a new DFI, we suggest that serial
plain radiographs of the affected foot be obtained to identify bone
abnormalities (deformity, destruction) as well as soft tissue gas and
radiopaque foreign bodies (2C).
➤ For those patients who require additional (ie, more sensitive or
specific) imaging, particularly when soft tissue abscess is suspected
or the diagnosis of osteomyelitis remains uncertain, we recommend
using magnetic resonance imaging (MRI) as the study of choice (1B).
• MRI is a valuable tool for diagnosis of osteomyelitis if the PTB test is inconclusive
of if the plain film is not useful.
➤ In patients with suspected DFO for whom MRI is contraindicated
or unavailable, we suggest a leukocyte or antigranulocyte scan,
preferably combined with a bone scan as the best alternative (2B).
➤ In patients at high risk for DFO, we recommend that the diagnosis
is most definitively established by the combined findings on
bone culture and histology (1C). When bone is débrided to treat
osteomyelitis, we recommend sending a sample for culture and
histology (1C).
➤ For patients not undergoing bone débridement, we suggest that
clinicians consider obtaining a diagnostic bone biopsy when faced
with diagnostic uncertainty, inadequate culture information, or failure
of response to empirical treatment (2C).
Table 1. Suggested Frequency for Follow-Up Evaluation
Category Risk profile Evaluation frequency
0 Normal Annual
1 Peripheral neuropathy Semiannual
2 Neuropathy with deformity
and/or PAD
Quarterly
3 Previous ulcer or amputation Monthly or quarterly
