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PubMed1985

Diagnostic strategies in osteomyelitis.

Technetium-99 (99Tc) pyrophosphate bone scanning often identifies patients with osteomyelitis before roentgenographic findings appear. However, recent studies have shown that 99Tc bone scanning often gives false-negative results, especially in neonates. The accuracy of computed tomographic scanning and indium-111 leukocyte scanning for diagnosis of early osteomyelitis has not been established. 99Tc bone scanning often gives false-positive results in patients with other conditions leading to bone injury and repair, such as trauma or recent surgery, further limiting the usefulness of this imaging procedure. Newer imaging techniques have not been adequately evaluated to establish their specificity. Because of their high cost and unproved accuracy, these new imaging procedures should not be routinely applied until their usefulness has been established. Bone biopsy remains the procedure of choice for establishing the diagnosis in patients suspected clinically to have osteomyelitis with negative findings on roentgenography and 99Tc bone scanning. Although Staphylococcus aureus is the leading cause of osteomyelitis, other pathogens cause 30 to 40 percent of cases. Aspiration or biopsy of the involved bone is usually required to choose appropriate antibiotic therapy. Bone biopsy is essential in chronic osteomyelitis, since cultures of sinus drainage are unreliable. Osteomyelitis in diabetics with foot infection and in association with decubitus ulcers presents special problems. Radionuclide scanning often give false-positive results in these patients. Proper diagnosis usually requires careful assessment of clinical and roentgenographic findings. Although bone biopsy seems useful in diagnosing osteomyelitis underlying decubitus ulcers, its role in diabetic patients with foot infections is not established. I do not recommend biopsy of foot bones in diabetic patients, since culture of bone biopsy specimens often give unreliable results in these situations because of contamination with ulcer organisms.

Acute Disease↗

PubMed1987

Candida osteomyelitis. Report of five cases and review of the literature.

Candida species have emerged as important pathogens in human infection. Although a variety of deep-seated candidal infections have been reported, Candida osteomyelitis has rarely been described. Five patients with Candida osteomyelitis are presented, and the 32 adult cases previously reported are reviewed. Candida osteomyelitis is noted as a simultaneous occurrence or late manifestation of hematogenously disseminated candidiasis. Osteomyelitis may not be prevented by a course of amphotericin B adequate to control the acute episode of disseminated candidiasis, particularly in immunosuppressed patients. Less commonly, Candida osteomyelitis presents as a postoperative wound infection. Like bacterial osteomyelitis, the most common presenting symptom is local pain. The insidious progression of infection, the nonspecificity of laboratory data, and the failure to recognize Candida as a potential pathogen may lead to diagnostic delay. Diagnosis can be made by either open biopsy or closed needle aspiration. Successful therapeutic regimens have employed combinations of antifungal therapy (most often amphotericin B) with surgical debridement when indicated. It is anticipated that osteomyelitis will become a more commonly recognized manifestation of hematogenously disseminated candidiasis.

Aged↗

PubMed2005

Diagnosis and classification of mandibular osteomyelitis.

To establish a unified classification system for mandibular osteomyelitis, various diagnostic terms were critically assessed and clinicopathologic findings of the lesions were carefully reviewed. We recommend classifying mandibular osteomyelitis into bacterial osteomyelitis and osteomyelitis associated with the synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome. Other diagnostic terms were excluded because they were not appropriate for classification. Diagnostic criteria for bacterial osteomyelitis are suppuration and osteolytic change. The lesions are easily cured by antibiotic treatments. Mandibular osteomyelitis in SAPHO syndrome is characterized by nonsuppuration and a mixed pattern on radiography, with solid type periosteal reaction, external bone resorption, and bone enlargement. The presence of osteomyelitis in other bones, arthritis, or skin diseases (palmoplantar pustulosis, pustular psoriasis, and acne) strongly suggests this syndrome. Antibiotic therapy is usually ineffective and the symptoms of SAPHO syndrome are often persistent.

Acquired Hyperostosis Syndrome↗

PubMed1991

Acute multilocular osteomyelitis in infancy and childhood.

38 cases of acute multilocular osteomyelitis out of a total of 165 osteomyelitis patients were treated between 1974 and 1986 at the Department of Paediatric Surgery and Paediatric Diseases at the University of Mainz. Osteomyelitis in infants was separated from juvenile osteomyelitis because of the different problems inherent to this disease depending upon the age; likewise, multilocular remote involvement was separated from regional multiple involvement. It was found that distant involvement is of special importance in infancy. 6 of the 8 cases in this group presented with symmetrical involvement. This interesting phenomenon is described in this article for the first time in acute multilocular osteomyelitis; so far, it was known to occur only in chronic recurrent multifocal osteomyelitis (CRMO). The infants in this group were predominantly newborn who were particularly severely handicapped by predisposing factors such as necessary intensive-care measures or surgical interventions. Our findings showed that in this age group most of the problems occurred, namely: 3 deaths and 2 healing defects in 8 children. For this reason it is imperative to effect particularly close monitoring of multilocular acute osteomyelitis in infancy. This must be considered as a paediatric and paediatric-surgical emergency requiring not only accurate diagnostic measures but also early internistic and surgical treatment to improve the prognosis of this specific disease pattern.

Acute Disease↗

PubMed2002

Osteomyelitis in elderly patients.

In elderly persons, osteomyelitis is second only to soft-tissue infection as the most important musculoskeletal infection. Acute osteomyelitis is usually acquired hematogenously, and the most common pathogen is Staphylococcus aureus. Acute osteomyelitis can usually be cured with antimicrobial therapy alone. In contrast, chronic osteomyelitis may be caused by S. aureus but is often due to gram-negative organisms. The causative organism of chronic osteomyelitis is identified by culture of aseptically obtained bone biopsy specimens. Because of the presence of infected bone fragments without a blood supply (sequestra), cure of chronic osteomyelitis with antibiotic therapy alone is rarely, if ever, possible. Adequate surgical debridement is the cornerstone of therapy for chronic osteomyelitis, and cure is not possible without the removal of all infected bone.

Acute Disease↗

PubMed2003

Role of oral antimicrobial therapy in the management of osteomyelitis.

PURPOSE OF REVIEW: Medical therapy of chronic osteomyelitis is largely based on experimental models, historical observational or non-randomized studies, and expert opinions. A minimum of 4-6 weeks of intravenous antimicrobial therapy targeting the causative organism, given in conjunction with surgery, has become the standard for chronic long-bone osteomyelitis in adults. Given the expense, inconvenience, and potential complications inherent to such a treatment program, alternative strategies including effective oral antimicrobial regimens are desirable. RECENT FINDINGS: Several oral antimicrobial agents have undergone evaluation for the treatment of acute and chronic osteomyelitis recently. These include fluoroquinolones, clindamycin, and linezolid. For the treatment of atypical causes of Gram-positive osteomyelitis, other oral therapies have been evaluated with reported success in small numbers of patients. SUMMARY: The standard of care for chronic osteomyelitis in adults remains intravenous antimicrobial therapy, in combination with surgery, for at least 4-6 weeks. Acute osteomyelitis in the pediatric population as well as osteomyelitis caused by atypical Gram-positive organisms and some Gram-negative organisms may be treated successfully with oral antibiotics. Some antimicrobials have equivalent concentration in serum whether administered orally or parenterally. When therapy with these antimicrobials is indicated, the oral route is preferred in compliant patients. As research continues in this area and as new drug formulations are developed, oral therapy may become an accepted alternative in additional selected patients.

Acute Disease↗

PubMed1993

Evaluation of postoperative osteomyelitis of the sternum comparing CT and dual Tc-99m MDP bone and In-111 WBC SPECT.

This article reports on a retrospective study of 32 patients who underwent CT and combined Tc-99m MDP and in-111 WBC SPECT between 1988 and 1991 for post-operative sternal osteomyelitis. Of these 32 patients, 7 patients (Group 1) underwent evaluation for possible sternal osteomyelitis due to persistent fevers, leukocytosis, or changes in the sternal incision; 12 patients (Group 2) had surgically proven osteomyelitis, and in 13 patients (Group 3) there was definite clinical evidence of sternal wound infection (however, surgical specimens of the sternum were not submitted). There was considerable overlap between the CT findings in the soft tissues adjacent to the sternum in Group 1 and Group 2 patients. Severe demineralization was seen in two patients, and erosion of the sternum was seen in five patients with proven osteomyelitis. Combined Tc-99m MDP bone and in-111 WBC SPECT was positive for osteomyelitis in 11 of 12 patients in Group 2. One patient with osteomyelitis had negative scintigraphy; however, this patient had a four-week course of IV antibiotic therapy prior to the study. All seven patients in Group 1 had negative SPECT scans and were treated successfully with oral antibiotics and minimal soft tissue debridement. Three patients in Group 3 had negative SPECT scans and were treated successfully with antibiotics and limited debridement. Ten patients with positive SPECT scans were treated with a combination of antibiotics and aggressive surgical intervention. In conclusion, CT findings in the soft tissues offer little specificity in distinguishing soft tissue inflammation from osteomyelitis of the sternum.(ABSTRACT TRUNCATED AT 250 WORDS)

Bone and Bones↗

PubMed1997

The clinical use of magnetic resonance imaging in pyogenic vertebral osteomyelitis.

STUDY DESIGN: Retrospective chart review of 103 cases. OBJECTIVES: To describe the clinical use of magnetic resonance imaging in a pyogenic vertebral osteomyelitis. SUMMARY OF BACKGROUND DATA: Long delays in diagnosing pyogenic vertebral osteomyelitis of the spine have been shown in many reports. Magnetic resonance imaging has been advocated as the imaging method of choice in suspected spinal infections. The use, accuracy, and timing of magnetic resonance imaging in pyogenic vertebral osteomyelitis have not been reported in a large series. METHODS: In 103 patients with pyogenic vertebral osteomyelitis who underwent magnetic resonance imaging at or before the time of diagnosis, the author reviewed the clinical findings and results of the magnetic resonance imaging, timing with respect to symptom duration and diagnosis, and accuracy of readings in detecting spinal infection. Follow-up magnetic resonance imaging reports also were reviewed. RESULTS: Magnetic resonance imaging appeared to give the correct diagnosis or suggest pyogenic vertebral osteomyelitis as a possible diagnosis in 55% and 36% of cases, respectively, with less than 2 weeks of symptoms. After 2 weeks, the percentages of correct and possible diagnoses of pyogenic vertebral osteomyelitis increased to 76% and 20%, respectively. Magnetic resonance imaging was obtained within 1 month of the start of symptoms in 73% of cases. The diagnosis was made within 1 month in the most cases as well, compared with a 2- to 6-month delay in most series. Follow-up magnetic resonance images often gave impressions of progressive disease, where the clinical picture appeared to improve. CONCLUSIONS: Magnetic resonance imaging is valuable in suggesting the diagnosis even very early in the clinical course of pyogenic vertebral osteomyelitis. Its use may eliminate significant delays in diagnosis. The use of magnetic resonance imaging in following the therapeutic response remains to be defined.

Bacterial Infections↗

PubMed2001

Zenker's diverticulum associated with multilevel cervical osteomyelitis.

STUDY DESIGN: A case report of cervical osteomyelitis possibly associated with a Zenker's diverticulum perforation. OBJECTIVES: To present clinical, radiologic, and surgical findings of a cervical osteomyelitis due to a Zenker's diverticulum perforation. SUMMARY OF BACKGROUND DATA: A 56-year-old patient was in an intensive care unit for a severe head injury. He was fed via a nasogastric tube. Four months later he developed a pyogenic cervical vertebral infection. METHODS: Plain films and magnetic resonance imaging showed a diffuse cervical osteomyelitis. Investigation of his dysphagia revealed a Zenker's diverticulum. RESULTS: After administration of antibiotics and surgical treatment of the diverticulum, the cervical infection resolved. Plain films and magnetic resonance imaging showed healing with vertebral fusion. CONCLUSIONS: Cervical osteomyelitis is uncommon. Only one case of direct contamination leading to cervical vertebral osteomyelitis after esophageal perforation has been previously described. Direct contamination of the prevertebral soft tissues by bacteria traveling through the fistula may have occurred. The development of vertebral osteomyelitis in this case is consistent with the hypothesis of direct contamination. Management relies on appropriate antimicrobial therapy and surgical management of the diverticulum. The association of Zenker's diverticulum with vertebral osteomyelitis and discitis is a unique, previously undescribed situation.

Anti-Infective Agents↗

PubMed2006

Recalcitrant septic knee arthritis due to adjacent osteomyelitis in adults.

We asked whether adjacent osteomyelitis with acute septic knee arthritis explained a lack of response to initial management, and whether patient comorbidities predisposed to the nonresponsiveness. From 147 adult patients (151 knees) with septic arthritis, we identified 29 patients (33 knees) who had persistence or recurrence of symptoms after surgical drainage. Adjacent osteomyelitis was present in 31 (94%) of the 33 knees (27 of 29 patients) with poor response to treatment. Patients with adjacent osteomyelitis had more comorbid conditions (23 of 27 patients, 85%) than patients without osteomyelitis (64 of 120, 53%). The most common comorbid conditions in patients with adjacent osteomyelitis were diabetes mellitus (10 patients, 37%) and intravenous drug use (eight patients, 30%). We identified Staphylococcus aureus in 19 of 31 knees (61%) with osteomyelitis, eight (26% of total cases) of which were methicillin-resistant. Persistence of clinical signs of infection after surgical management of septic knee arthritis in adults should raise the suspicion of adjacent osteomyelitis, especially in patients with comorbid conditions. Additional imaging studies may be necessary to evaluate the distal femur and proximal tibia.

Adult↗

PubMed1982

Precipitating antibodies against Staphylococcus aureus in serum from patients with staphylococcal osteomyelitis, investigated by means of quantitative immunoelectrophoretic methods.

By means of crossed immunoelectrophoresis, precipitating antibodies against 55 Staphylococcus aureus antigens were investigated in serum from 11 patients with acute osteomyelitis and 47 patients with chronic osteomyelitis. Patients with acute osteomyelitis had an increase antibody response, expressed as a precipitin score, compared to normal persons, while patients with chronic osteomyelitis had an almost normal response. The precipitin score in patients with acute osteomyelitis was significantly higher than in patients with chronic osteomyelitis (p less than 0.01). However, patients with chronic osteomyelitis increased their precipitin score during an active phase of the infection.

Acute Disease↗

PubMed1995

Study of osteomyelitis: utility of combined histologic and microbiologic evaluation of percutaneous biopsy samples.

PURPOSE: To determine the utility of combined histologic and microbiologic evaluation of percutaneous biopsy samples in cases of suspected osteomyelitis. MATERIALS AND METHODS: Twenty-five patients with suspected osteomyelitis were prospectively studied over a 1-year period. With usual trephine techniques under radiologic guidance, core and aspiration biopsy samples were obtained in each patient for both histologic and microbiologic analyses. RESULTS: Sixteen biopsy specimens demonstrated histologic evidence of osteomyelitis. Of these, eight were also culture positive. Seven of the eight culture-negative, histologically positive cases were interpreted as chronic osteomyelitis. In no patient were cultures positive and histologic findings negative. Three of 19 patients with proved osteomyelitis had negative histologic and microbiologic findings. The sensitivity of culture in the diagnosis of osteomyelitis in our study was 42%; the sensitivity of both culture and histologic findings was 84%. CONCLUSION: Although the volume of a biopsy specimen is a major determinant of culture yield, a portion of a percutaneous biopsy sample should be histologically evaluated for possible osteomyelitis.

Acute Disease↗

PubMed1997

Osteomyelitis of the diabetic foot: MR imaging-pathologic correlation.

PURPOSE: To evaluate the efficacy of magnetic resonance (MR) imaging for the diagnosis of osteomyelitis in the diabetic foot by using anatomic and histologic studies of the resected tissue as a standard of reference. MATERIALS AND METHODS: Thirteen diabetic patients with high clinical suspicion of osteomyelitis underwent a total of 15 MR examinations before surgery. Correlation was made between MR findings and the histologic features of the resected tissue, which included 57 bones. RESULTS: Maximum signal intensity on the T2-weighted or short inversion time inversion-recovery images of the bones was due to osteomyelitis (prospective sensitivity, 90%; specificity, 71%). Eighteen bones with increased signal intensity showed only edema of the marrow. The range of signal intensity in edema overlapped that in osteomyelitis but was lower. The use of gadopentetate dimeglumine improved delineation of soft-tissue inflammatory masses, but this contrast material was not useful in distinguishing osteomyelitis from edema. CONCLUSION: Marrow edema cannot be reliably distinguished from osteomyelitis with MR imaging. Gadopentetate dimeglumine is of limited use. Some previously published false-positive reports of osteomyelitis were most likely due to edema of the marrow. MR imaging is useful in planning surgery of the infected diabetic foot, as it enables reliable distinction between normal and abnormal areas.

Adult↗

PubMed2004

Wound-related osteomyelitis: a case of containment not cure.

Community nurses need to be aware that some patients with osteomyelitis are treated with antibiotics alone. Such patients often have co-morbidities and quality of life issues that directly impact on the decision to treat osteomyelitis surgically. However, adopting a conservative approach to osteomyelitis management is associated with an increased risk of osteomyelitis recurrence. The rationale for managing chronic wound-related osteomyelitis with antibiotics is discussed. Community nurses caring for patients that have received antibiotics alone to treat osteomyelitis need to be aware of the potential for osteomyelitis recurrence and how to make the diagnosis.

Adult↗

PubMed2005

The accuracy of diagnostic imaging for the assessment of chronic osteomyelitis: a systematic review and meta-analysis.

BACKGROUND: A variety of diagnostic imaging techniques is available for excluding or confirming chronic osteomyelitis. Until now, an evidence-based algorithmic model for choosing the most suitable imaging technique has been lacking. The objective of this study was to determine the accuracy of current imaging modalities in the diagnosis of chronic osteomyelitis. METHODS: A systematic review and meta-analysis of the literature was conducted with a comprehensive search of the MEDLINE, EMBASE, and Current Contents databases to identify clinical studies on chronic osteomyelitis that evaluated diagnostic imaging modalities. The value of each imaging technique was studied by determining its sensitivity and specificity compared with the results of histological analysis, findings on culture, and clinical follow-up of more than six months. RESULTS: A total of twenty-three clinical studies in which the accuracy was described for radiography (two studies), magnetic resonance imaging (five), computed tomography (one), bone scintigraphy (seven), leukocyte scintigraphy (thirteen), gallium scintigraphy (one), combined bone and leukocyte scintigraphy (six), combined bone and gallium scintigraphy (three), and fluorodeoxyglucose positron emission tomography (four) were included in the review. No meta-analysis was performed with respect to computed tomography, gallium scintigraphy, and radiography. Pooled sensitivity demonstrated that fluorodeoxyglucose positron emission tomography was the most sensitive technique, with a sensitivity of 96% (95% confidence interval, 88% to 99%) compared with 82% (95% confidence interval, 70% to 89%) for bone scintigraphy, 61% (95% confidence interval, 43% to 76%) for leukocyte scintigraphy, 78% (95% confidence interval, 72% to 83%) for combined bone and leukocyte scintigraphy, and 84% (95% confidence interval, 69% to 92%) for magnetic resonance imaging. Pooled specificity demonstrated that bone scintigraphy had the lowest specificity, with a specificity of 25% (95% confidence interval, 16% to 36%) compared with 60% (95% confidence interval, 38% to 78%) for magnetic resonance imaging, 77% (95% confidence interval, 63% to 87%) for leukocyte scintigraphy, 84% (95% confidence interval, 75% to 90%) for combined bone and leukocyte scintigraphy, and 91% (95% confidence interval, 81% to 95%) for fluorodeoxyglucose positron emission tomography. The sensitivity of leukocyte scintigraphy in detecting chronic osteomyelitis in the peripheral skeleton was 84% (95% confidence interval, 72% to 91%) compared with 21% (95% confidence interval, 11% to 38%) for its detection of chronic osteomyelitis in the axial skeleton. The specificity of leukocyte scintigraphy in the axial skeleton was 60% (95% confidence interval, 39% to 78%) compared with 80% (95% confidence interval, 61% to 91%) for the peripheral skeleton. CONCLUSIONS: Fluorodeoxyglucose positron emission tomography has the highest diagnostic accuracy for confirming or excluding the diagnosis of chronic osteomyelitis. Leukocyte scintigraphy has an appropriate diagnostic accuracy in the peripheral skeleton, but fluorodeoxyglucose positron emission tomography is superior for detecting chronic osteomyelitis in the axial skeleton.

Chronic Disease↗

PubMed1999

Use of quinolones in osteomyelitis and infected orthopaedic prosthesis.

The present review provides an updated critical analysis of the use of quinolones in osteomyelitis and orthopaedic prosthetic infections. Only papers published in peer-reviewed journals and related to the following areas were selected: experimental osteomyelitis, penetration of quinolones into human bone, and clinical use in comparative and noncomparative studies. Local drug carriers impregnated with quinolones allow high local antibiotic concentrations to be achieved in experimental systems. Considerable clinical experience has been gained mostly with ciprofloxacin and ofloxacin. Cumulated results in clinical trials show clinical success rates of more than 90% in osteomyelitis caused by Enterobacteriaceae. The combination of quinolones and rifampicin for the treatment of staphylococcal osteomyelitis as well as orthopaedic prosthetic infections appears very promising in clinical studies with a small number of patients. However, further comparative studies using quinolones as single agents or in combination (versus standard parenteral therapy) remain necessary in osteomyelitis due to Staphylococcus aureus or Pseudomonas aeruginosa. In particular, studies with the newer quinolones should be strongly encouraged in acute or chronic osteomyelitis and in more complicated situations such as diabetic osteomyelitis or foreign-body infection.

4-Quinolones↗

PubMed1999

Diagnosis and management of osteomyelitis. Decision analytic and pharmacoeconomic considerations.

Osteomyelitis, or bone infection, is becoming more common, largely because of increases in the use of implanted prosthetic devices in the management of arthritis or fractures. The clinical management of osteomyelitis requires accurate microbiological diagnosis that will identify appropriate antibacterials to which the pathogenic organisms are sensitive. Therapy will largely depend on the type of bacteria, the route by which the bacteria reach the bone, the presence of any orthopaedic devices and the patient's ability to mount an immune response. Consequently, therapy often requires a combination of medical and surgical management. The aim of this review is primarily to assess the impact of different drug regimens on the total cost and to clarify the implications of various treatment options for patients with osteomyelitis. Thus, the review examines the link between the main categories of osteomyelitis and common pathogens, and provides additional comments on the aetiology and epidemiology of the condition. At present, there is a real shortage of high quality evidence to guide the decision-maker through the range of available options. One way to deal with the complexity and uncertainty surrounding the management of osteomyelitis is to develop treatment protocols leading to decision trees which will in turn systematically analyse the options available for treating patients with osteomyelitis. Consequently, we have developed a number of decision trees to show the range of options available and have applied these to the relatively simple problem of route of administration of antibacterials. However, even here the available data allow only relatively crude estimations of the costs and consequences of alternative regimens. Thus, the aim has been to provide structures that may help to set priorities for research based on the expected value of new information. In the absence of evidence, there are broadly 2 alternatives. One is based on selection of the least expensive regimen in the absence of evidence to prove that more expensive options are more effective; patients with multiply resistant staphylococci, for which no effective oral regimen is available, should be treated with intravenous therapy. This is consistent with the UK legal system, which is founded on the so-called Bolam test. The alternative is providing the maximum available treatment; in the US, it is more likely that a doctor will be held negligent for not providing the maximum available treatment, and most standard texts recommend routine use of intravenous therapy for osteomyelitis.

Anti-Bacterial Agents↗

PubMed1991

Diagnosis of osteomyelitis in the presence of soft-tissue infection and radiologic evidence of osseous abnormalities: value of leukocyte scintigraphy.

To evaluate the usefulness of 111In-leukocyte scintigraphy for identifying osteomyelitis in the presence of soft-tissue infection, we prospectively studied 45 bone sites adjacent to soft-tissue infection in patients with abnormal findings on radiographs and 99mTc bone scans that were suggestive of osteomyelitis. 111In-leukocyte scans were analyzed in terms of the intensity of abnormal uptake and its location relative to bone. The diagnosis of osteomyelitis was established from results of percutaneous bone biopsy culture (n = 35), histologic examination of surgical specimens (n = 8), and clinical follow-up (n = 2). Osteomyelitis was present at 22 sites, including 16 of 18 sites with increased leukocyte uptake in bone, resulting in a sensitivity of 73%, specificity of 91%, and positive predictive value of 89% for this finding. Osteomyelitis was present at four of 17 sites with predominantly soft-tissue localization of leukocyte activity in the region of bone, none of seven sites with normal leukocyte scans, and two of three sites with diminished leukocyte uptake in bone. Although not helpful in distinguishing infectious from noninfectious bone abnormalities, 3- and especially 24-hr bone scans viewed in conjunction with leukocyte studies provided important correlation to aid in estimating the location of focal abnormal leukocyte uptake. The finding of soft-tissue infection with increased uptake of labeled leukocytes that extends to involve adjacent bone strongly suggests concurrent osteomyelitis. When the presence of abnormal leukocyte uptake in bone is uncertain, additional imaging and possibly biopsy may be required to establish or exclude the diagnosis of osteomyelitis.

Adult↗