Diabetic Foot Infections and the Hospitalist

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  • Failure to adequately treat results from knowledge deficits, failure to appropriately allocate resources and insufficient multidisciplinary cooperation.
  • DFI: an inframalleolar infx in a diabetic.
  • Chronic, heavily abt exposed infxs may also feature enterococcus, diphteroids, other non-fermenters. Hospitalization, prior abts may predispose to HA-MRSA (obviously not necessary for CA-MRSA). Foot soaking as a risk factor for Pseudomonas. Recent Falagas review here?
  • CNS, enterococcus, Pseudomonas, diphtheroids can clearly all be pathogenic, but are frequently not. Impaired host defenses in milieu of necrotic ST and bone probably play role in allowing low virulence bugs (CNS, diphtheroids) to become pathogens.
  • Blood cultures in pts systemically ill. Needle aspiration an option for sampling abscesses/purulent collections.
  • Distinction between moderate and severe infections has less to do with the foot, and more to do with “the patient to whom it is attached.” Up to 50% of pts will not show evidence of systemic illness even with severe/limb-threatening infx. Other pts will demonstrate only loss of glycemic control as manifestation of severe dx.
  • Next 3 slides are EMPIRIC regimens.
  • Daptomycin and linezolid 'when MRSA proven or likely.'
  • Vancomycin regimen 'when MRSA proven or likely'.
  • Pus under pressure in foot can rapidly lead to permanent damage. Higher level amputation will sometimes be preferable to lower level amp, if latter unlikely to heal, to leave mechanically unsound foot, or if ulceration recurrent. With regard to ischemia, ABI of 0.5-0.9 suggests mild-mod disease, with wound that should be healable without revasc. Palp DP/PT likewise predict absence of severe ischemia.
  • 75K admits annually in US (ie, OM of feet)
  • Kline A, Internet J of Pod 2007;2:3. Kline A, thefootblog.org.
  • 2-4 week delay in radiographic appearance of OM.
  • Above sens/spec concerns apply to technetium 3-phase. WBC tagged studies improve spec, but at cost of lower sensitivity.
  • Cortical disruption, sinus tract, adjacent ST changes also help to suggest dx.
  • 17 total studies selected. 7 compared bone scan to MRI, 9 compared MRI to plain films. Most studies don't use bone bx as gold standard.
  • Authors conclude MRI clinches dx when other evidence supports OM (PTB, deep ulcer); and also conclude that bone scanning has very limited role in this setting. 2006 Medicare outpt reimbursement for bone scan $288, for MRI of foot with contrast $451.
  • Staph aureus most common isolate in both bone and ulcer cxs. Bone bx appeared safe/well tolerated. 1 pt had acute Charcot foot 4 weeks later, ? relationship. Theoretical concerns with bone bx have included introducing infx, bone fx, failure to heal. Staph aureus and CNS both made up 26% of bone bx + cultures.
  • Some advocate that only necrotic bone (rather than all infected bone) be removed. Game/Jeffcoate series: amputations done either for limb/life-threatening infxs, or non-response to abts. Majority of those treated medically received all-PO regimens, with average duration of Tx 61 days. Importantly, series was consecutive (though retrospective).
  • Diabetic Foot Infections and the Hospitalist

    1. 1. Diabetic Foot Infections and theDiabetic Foot Infections and the HospitalistHospitalist Jim Pile, MD, FACPJim Pile, MD, FACP Divisions of Hospital Medicine andDivisions of Hospital Medicine and Infectious DiseasesInfectious Diseases CWRU/MetroHealth Medical CenterCWRU/MetroHealth Medical Center
    2. 2. The ProblemThe Problem • Diabetic foot infections are common, expensiveDiabetic foot infections are common, expensive and probably increasing in frequencyand probably increasing in frequency • The most frequent reason for hospitalization inThe most frequent reason for hospitalization in diabetic patientsdiabetic patients • The most common reason for amputationsThe most common reason for amputations • Current treatment often fails to conform toCurrent treatment often fails to conform to available evidence/guidelinesavailable evidence/guidelines
    3. 3. Scope of Diabetic Foot InfectionsScope of Diabetic Foot Infections • CellulitisCellulitis • ParonychiaParonychia • AbscessAbscess • MyositisMyositis • Infectious tendonitisInfectious tendonitis • Septic arthritisSeptic arthritis • Necrotizing fasciitisNecrotizing fasciitis • OsteomyelitisOsteomyelitis • ULCERSULCERS
    4. 4. Risk Factors for Diabetic FootRisk Factors for Diabetic Foot Ulceration and InfectionUlceration and Infection • Sensory neuropathySensory neuropathy • Motor neuropathyMotor neuropathy • Autonomic neuropathyAutonomic neuropathy • Neuro-osteoarthropathicNeuro-osteoarthropathic deformities (eg Charcot)deformities (eg Charcot) • Peripheral vascularPeripheral vascular diseasedisease • HyperglycemiaHyperglycemia • Host factorsHost factors • Patient non-adherencePatient non-adherence • Sub-optimal care bySub-optimal care by health care systemhealth care system
    5. 5. Audience Response QuestionAudience Response Question • Treatment of cellulitis in the patient withTreatment of cellulitis in the patient with longstanding diabetes should include coveragelongstanding diabetes should include coverage of:of: A. Gram positive organismsA. Gram positive organisms B. Gram positive and negative organismsB. Gram positive and negative organisms C. Gram positives and anaerobesC. Gram positives and anaerobes D. All of the aboveD. All of the above
    6. 6. Microbiology of Diabetic Foot InfectionsMicrobiology of Diabetic Foot Infections • Gram positive organisms predominate,Gram positive organisms predominate, especially in acute woundsespecially in acute wounds --Staph aureus--Staph aureus --B-hemolytic strep (especially groups A and B)--B-hemolytic strep (especially groups A and B) • Chronic wounds and/or recent antibiotics:Chronic wounds and/or recent antibiotics: --Enterobacteriaceae (and gram positives)--Enterobacteriaceae (and gram positives) • Chronic, heavily treated infections:Chronic, heavily treated infections: --Coag neg Staph, Pseudomonas, anaerobes (+ above)--Coag neg Staph, Pseudomonas, anaerobes (+ above)
    7. 7. Microbiology of DFIsMicrobiology of DFIs • Polymicrobial wounds typically demonstrate 3-5Polymicrobial wounds typically demonstrate 3-5 pathogens on culturepathogens on culture • Significance of all of these often unclear,Significance of all of these often unclear, howeverhowever • Limb (and life) threatening infections should beLimb (and life) threatening infections should be assumed to be polymicrobial until provenassumed to be polymicrobial until proven otherwiseotherwise
    8. 8. Wound CultureWound Culture • Neglected or done incorrectly much of timeNeglected or done incorrectly much of time • Don’tDon’t culture uninfected ulcers!culture uninfected ulcers! • Failure to debride wound before culture aFailure to debride wound before culture a common mistakecommon mistake • Tissue from debrided ulcer base providesTissue from debrided ulcer base provides optimal material for cultureoptimal material for culture • But swab fromBut swab from debrideddebrided ulcer also acceptableulcer also acceptable
    9. 9. Staging Severity of InfectionStaging Severity of Infection • Staging classification adopted by InternationalStaging classification adopted by International Consensus on Diabetic Foot and IDSA utilizes PEDISConsensus on Diabetic Foot and IDSA utilizes PEDIS acronym:acronym: --PP: perfusion: perfusion --EE: extent/size: extent/size --DD: depth/tissue loss: depth/tissue loss --II: infection: infection --SS: sensation: sensation --Lipsky B, Clin Infect Dis 2004;39:885Lipsky B, Clin Infect Dis 2004;39:885
    10. 10. DFI StagingDFI Staging • Uninfected (PEDIS 1)Uninfected (PEDIS 1) • Mild infection (PEDIS 2)Mild infection (PEDIS 2) --Superficial, cellulitis < 2 cmSuperficial, cellulitis < 2 cm • Moderate infection (PEDIS 3)Moderate infection (PEDIS 3) --Cellulitis > 2 cm, lymphangitis, abscess, gangreneCellulitis > 2 cm, lymphangitis, abscess, gangrene • Severe infection (PEDIS 4)Severe infection (PEDIS 4) --Systemic involvement (fever, hypotension, leukocytosis,Systemic involvement (fever, hypotension, leukocytosis, severe hypoglycemia, renal failure, etc.)severe hypoglycemia, renal failure, etc.)
    11. 11. Admission CriteriaAdmission Criteria • Essentially all patientsEssentially all patients with severe infection, andwith severe infection, and some with moderate,some with moderate, require hospitalizationrequire hospitalization • Most patients with mildMost patients with mild infection may be treatedinfection may be treated as outpatientsas outpatients • Reasons for admissionReasons for admission:: -Systemic toxicity-Systemic toxicity -Severe metabolic-Severe metabolic disturbancesdisturbances -Rapid progression-Rapid progression -Critical ischemia-Critical ischemia -Unable to care for self-Unable to care for self -Need for urgent diagnostic or-Need for urgent diagnostic or therapeutic interventionstherapeutic interventions
    12. 12. Audience Response QuestionAudience Response Question • A 44 year old woman withA 44 year old woman with poorly controlled T2DMpoorly controlled T2DM and a plantar ulcer to theand a plantar ulcer to the R great toe of > 1 monthR great toe of > 1 month duration presents withduration presents with several days ofseveral days of progressive pain,progressive pain, erythema and swelling oferythema and swelling of the foot. Tc is 38.4the foot. Tc is 38.4° C,° C, her WBC is 14K and herher WBC is 14K and her BS is > 400.BS is > 400.
    13. 13. Audience Response QuestionAudience Response Question • Which of the following antibiotic regimens isWhich of the following antibiotic regimens is MOST appropriate?MOST appropriate? A. MeropenemA. Meropenem B. Ciprofloxacin + metronidazoleB. Ciprofloxacin + metronidazole C. Piperacillin-tazobactam + vancomycinC. Piperacillin-tazobactam + vancomycin D. Clindamycin + levofloxacinD. Clindamycin + levofloxacin
    14. 14. Antibiotic TherapyAntibiotic Therapy • Does the patient need antibiotics?Does the patient need antibiotics? • Choice of agent will be dictated by severity ofChoice of agent will be dictated by severity of infection as well as chronicityinfection as well as chronicity • Difficult to make definitive recommendationsDifficult to make definitive recommendations based on available databased on available data
    15. 15. Mild Diabetic Foot InfectionsMild Diabetic Foot Infections • DicloxacillinDicloxacillin • ClindamycinClindamycin • CephalexinCephalexin • Trimethoprim-Trimethoprim- SulfamethoxazoleSulfamethoxazole • LevofloxacinLevofloxacin • How does progressiveHow does progressive emergence of CA-MRSAemergence of CA-MRSA affect theseaffect these recommendations?recommendations? • Ideal regimen will reliablyIdeal regimen will reliably cover CA-MRSA and B-cover CA-MRSA and B- hemolytic Strephemolytic Strep
    16. 16. Moderate DFIModerate DFI • Trimethoprim-Trimethoprim- sulfamethoxazolesulfamethoxazole • Amox/clavulanateAmox/clavulanate • LevofloxacinLevofloxacin • CefoxitinCefoxitin • CeftriaxoneCeftriaxone • Amp/sulbactamAmp/sulbactam • Linezolid (+/- aztreonam)Linezolid (+/- aztreonam) • Daptomycin (+/-Daptomycin (+/- aztreonam)aztreonam) • ErtapenemErtapenem • Cefuroxime +/-Cefuroxime +/- metronidazolemetronidazole • Piperacillin/tazobactamPiperacillin/tazobactam • FQ + clindamycinFQ + clindamycin
    17. 17. Severe DFIsSevere DFIs • Piperacillin-tazobactamPiperacillin-tazobactam • LevofloxacinLevofloxacin oror ciprofloxacin + clindamycinciprofloxacin + clindamycin • Imipenem-cilastatinImipenem-cilastatin • Vancomycin + ceftazidime (+/- metronidazole)Vancomycin + ceftazidime (+/- metronidazole)
    18. 18. Surgical IndicationsSurgical Indications • Urgent:Urgent: -Gas gangrene-Gas gangrene -Necrotizing fasciitis-Necrotizing fasciitis -Compartment syndrome-Compartment syndrome -Critical ischemia-Critical ischemia • Other indications:Other indications: -Abscess-Abscess -Progressive infection-Progressive infection despite antibioticsdespite antibiotics -Unexplained foot pain-Unexplained foot pain -Need for ulcer-Need for ulcer debridementdebridement
    19. 19. Goals of SurgeryGoals of Surgery • Drainage of pusDrainage of pus • Correction of severe ischemiaCorrection of severe ischemia • Control of infectionControl of infection • Salvage of functional footSalvage of functional foot • Surgical expertise varies locallySurgical expertise varies locally
    20. 20. Important Adjuncts to UlcerImportant Adjuncts to Ulcer HealingHealing • Off-loadingOff-loading -Mechanical stress on ulcerated area MUST be prevented-Mechanical stress on ulcerated area MUST be prevented -Bedrest, crutches, surgical/half shoes, removable cast walker, etc.-Bedrest, crutches, surgical/half shoes, removable cast walker, etc. • DebridementDebridement -Sharp debridement generally preferable-Sharp debridement generally preferable • Appropriate dressingAppropriate dressing -Moist wound environment promotes epithelialization-Moist wound environment promotes epithelialization -Many commercial products available, none clearly superior-Many commercial products available, none clearly superior
    21. 21. Emerging TherapyEmerging Therapy • Hyperbaric oxygenHyperbaric oxygen • Negative pressure dressingsNegative pressure dressings • G-CSFG-CSF • Maggot therapyMaggot therapy • None of above should be a substitute forNone of above should be a substitute for appropriate antibiotics and surgical therapyappropriate antibiotics and surgical therapy
    22. 22. Discharge CriteriaDischarge Criteria • No evidence-basedNo evidence-based criteria existcriteria exist • Extrapolating fromExtrapolating from community-acquiredcommunity-acquired pneumonia literature, aspneumonia literature, as a minimum the followinga minimum the following should be met:should be met: • TT ≤ 37.8 C≤ 37.8 C • Blood pressure > 90Blood pressure > 90 • Pulse < 100Pulse < 100 • Mental status at baselineMental status at baseline -Mandell LA, IDSA/ATS Consensus-Mandell LA, IDSA/ATS Consensus Guidelines on the Management of CAPGuidelines on the Management of CAP in Adults. CID 2007;44:S27-72.in Adults. CID 2007;44:S27-72.
    23. 23. Discharge CriteriaDischarge Criteria • Adequate glycemic control should be presentAdequate glycemic control should be present • Any immediately necessary surgery should beAny immediately necessary surgery should be accomplishedaccomplished • Clear wound care and off-loading plans shouldClear wound care and off-loading plans should be outlined and clear to patientbe outlined and clear to patient • Definitive antibiotic regimen selectedDefinitive antibiotic regimen selected • Site of care, follow-up appointments andSite of care, follow-up appointments and communication with PCPcommunication with PCP
    24. 24. "Dealing with osteomyelitis is perhaps"Dealing with osteomyelitis is perhaps the most difficult and controversialthe most difficult and controversial aspect in the management of diabeticaspect in the management of diabetic foot infections."foot infections." -Lipsky BA. Diagnosis and Treatment of Diabetic Foot-Lipsky BA. Diagnosis and Treatment of Diabetic Foot Infections. Clin Infect Dis 2004;39:885-910Infections. Clin Infect Dis 2004;39:885-910
    25. 25. Suspect Osteomyelitis When . . . .Suspect Osteomyelitis When . . . . • An ulcer is chronic orAn ulcer is chronic or overlies boneoverlies bone • An ulcer fails to heal afterAn ulcer fails to heal after ≥ 6 weeks of appropriate≥ 6 weeks of appropriate treatmenttreatment • A "sausage toe" isA "sausage toe" is presentpresent • A swollen foot is presentA swollen foot is present with a history of footwith a history of foot ulcerationulceration • An ulcer is accompaniedAn ulcer is accompanied by otherwise unexplainedby otherwise unexplained elevated ESR/CRPelevated ESR/CRP • Bone is visible or can beBone is visible or can be probed in an ulcer baseprobed in an ulcer base • Any ulcer that is deep orAny ulcer that is deep or extensiveextensive • Ulcer area is > 2 cmUlcer area is > 2 cm²² -Lipsky B, CID 2004;39:885; Butalia S,-Lipsky B, CID 2004;39:885; Butalia S, JAMA 2008;299:806JAMA 2008;299:806
    26. 26. Audience Response QuestionAudience Response Question • The single BEST test for the diagnosis ofThe single BEST test for the diagnosis of osteomyelitis in the diabetic foot is:osteomyelitis in the diabetic foot is: A. WBC-tagged nuclear scanA. WBC-tagged nuclear scan B. Positive probe-to-bone testB. Positive probe-to-bone test C. MRIC. MRI D. FDG-PETD. FDG-PET
    27. 27. Osteomyelitis of the Foot: DiagnosticOsteomyelitis of the Foot: Diagnostic ChallengesChallenges • Distinction between soft tissue and OM (orDistinction between soft tissue and OM (or uninfected ulcer and OM) frequently unclearuninfected ulcer and OM) frequently unclear • Changes on plain XR delayed and inconsistentChanges on plain XR delayed and inconsistent • Lab values don't provide resolution between OMLab values don't provide resolution between OM and STIand STI • Neuro-osteoarthropathy (Charcot) may mimicNeuro-osteoarthropathy (Charcot) may mimic OMOM • Advanced imaging is expensiveAdvanced imaging is expensive
    28. 28. Plain FilmsPlain Films • Simple and cheapSimple and cheap • Radiographic changesRadiographic changes lag clinical pathologylag clinical pathology • Recent review foundRecent review found sensitivity/specificitysensitivity/specificity 61%/72%61%/72% • Probably underutilizedProbably underutilized --Learch T, Advanced Imaging of theLearch T, Advanced Imaging of the Diabetic Foot and its Complications.Diabetic Foot and its Complications. www.gentili.net/diabeticfoot.www.gentili.net/diabeticfoot.
    29. 29. Nuclear Medicine ImagingNuclear Medicine Imaging • Sensitivity is highSensitivity is high • Relatively expensiveRelatively expensive • Time consumingTime consuming • Specificity is problematicSpecificity is problematic • WBC-tagged scans mayWBC-tagged scans may be helpful inbe helpful in distinguishing Charcotdistinguishing Charcot arthropathy from OMarthropathy from OM --Lipman B, Clin Nucl Med 1998,23:77Lipman B, Clin Nucl Med 1998,23:77
    30. 30. MRIMRI • Focal decrease in marrow signal on T1-weightedFocal decrease in marrow signal on T1-weighted and increase on fat-suppressed T2-weightedand increase on fat-suppressed T2-weighted images suggests diagnosis of osteomyelitisimages suggests diagnosis of osteomyelitis • Sensitivity highSensitivity high • Much more specific than nuclear studiesMuch more specific than nuclear studies • Expense suggests MRI may be over-utilized inExpense suggests MRI may be over-utilized in this settingthis setting
    31. 31. MRI vs. Other Imaging ModalitiesMRI vs. Other Imaging Modalities • Recent meta-analysis found that at sensitivity ofRecent meta-analysis found that at sensitivity of 90%, specificity of MRI for foot osteomyelitis90%, specificity of MRI for foot osteomyelitis was 83%was 83% • MRI markedly better than nuclear studies orMRI markedly better than nuclear studies or plain filmsplain films • DOR 150 vs. 3.6 for MRI vs. bone scanDOR 150 vs. 3.6 for MRI vs. bone scan • DOR 82 vs. 3.3 for MRI vs. plain filmsDOR 82 vs. 3.3 for MRI vs. plain films -- Kapoor, A. et al. Arch Intern Med 2007;167:125-132.
    32. 32. Kapoor, A. et al. Arch Intern Med 2007;167:125-132.
    33. 33. Probe-to-Bone TestProbe-to-Bone Test • Bedside test touted asBedside test touted as low-tech means oflow-tech means of diagnosisdiagnosis • Positive predictive valuePositive predictive value reported as 89%reported as 89% • Recent studies suggestRecent studies suggest caution with generalizingcaution with generalizing these resultsthese results -Grayson M, JAMA 1995;273:721;-Grayson M, JAMA 1995;273:721; Shone A, Diab Care 2006;29:945;Shone A, Diab Care 2006;29:945; Lavery L, Diab Care 2007;30:270Lavery L, Diab Care 2007;30:270
    34. 34. Probe-to-Bone Characteristics DependProbe-to-Bone Characteristics Depend on Prevalence of Osteomyelitison Prevalence of Osteomyelitis SensSens SpecSpec PPVPPV NPVNPV PrevPrev GraysonGrayson 66%66% 85%85% 89%89% 56%56% 66%66% ShoneShone 38%38% 91%91% 53%53% 85%85% 20%20% LaveryLavery 87%87% 91%91% 57%57% 98%98% 12%12%
    35. 35. Bone BiopsyBone Biopsy • 76 patients with 81 episodes of DFO confirmed76 patients with 81 episodes of DFO confirmed by bone biopsyby bone biopsy • 69 cases had ulcer swab cultures as well69 cases had ulcer swab cultures as well • Bone biopsy isolates: 77% gram +, 18% gramBone biopsy isolates: 77% gram +, 18% gram negative, 5% anaerobesnegative, 5% anaerobes • Bone/ulcer cxs concordant in 17%Bone/ulcer cxs concordant in 17% • 70% of ulcer cxs did not grow bone pathogen(s)70% of ulcer cxs did not grow bone pathogen(s) --Senneville E, Clin Infect Dis 2006;42:57Senneville E, Clin Infect Dis 2006;42:57
    36. 36. IDSA Guidelines Approach toIDSA Guidelines Approach to Suspected Diabetic Foot OMSuspected Diabetic Foot OM • 1. Begin with plain films of foot1. Begin with plain films of foot -If c/w osteomyelitis, treat as such-If c/w osteomyelitis, treat as such • 2. If plain films2. If plain films notnot suggestive of osteomyelitissuggestive of osteomyelitis A. "Conservative approach":A. "Conservative approach": --Treat soft tissue infx for 2-4 weeks, then--Treat soft tissue infx for 2-4 weeks, then repeat XRrepeat XR B. "Aggressive approach":B. "Aggressive approach": --Obtain MRI (or nuclear scan)--Obtain MRI (or nuclear scan)
    37. 37. Osteomyelitis: Medical vs. SurgicalOsteomyelitis: Medical vs. Surgical TreatmentTreatment • Traditional thinking mandates resection ofTraditional thinking mandates resection of infected boneinfected bone • Even limited amputations may adversely affectEven limited amputations may adversely affect foot mechanics, setting up vicious cyclefoot mechanics, setting up vicious cycle • Slowly mounting evidence that many cases ofSlowly mounting evidence that many cases of diabetic foot OM respond to antibiotics alonediabetic foot OM respond to antibiotics alone • Recent study of 147 pts found 77% treatedRecent study of 147 pts found 77% treated medically, with good result in 82% of thesemedically, with good result in 82% of these -Game FL, Diabetologia DOI 10.1007/s00125-008-0976-1-Game FL, Diabetologia DOI 10.1007/s00125-008-0976-1
    38. 38. Audience Response QuestionAudience Response Question • A 53 y.o. diabetic patient is admitted to yourA 53 y.o. diabetic patient is admitted to your service with an erythematous, swollen right 3service with an erythematous, swollen right 3rdrd toe and forefoot cellulitis. The toe infectiontoe and forefoot cellulitis. The toe infection appears to have been prompted by a plantarappears to have been prompted by a plantar ulcer of several weeks duration. An MRIulcer of several weeks duration. An MRI strongly suggests osteomyelitis of the proximalstrongly suggests osteomyelitis of the proximal and distal phalanges of the 3and distal phalanges of the 3rdrd toe, and shetoe, and she undergoes ray resection. How long should sheundergoes ray resection. How long should she be treated with antibiotics post-operatively?be treated with antibiotics post-operatively?
    39. 39. ARS (continued)ARS (continued) A. She doesn't require additional antibiotics, theA. She doesn't require additional antibiotics, the non-viable bone has been removednon-viable bone has been removed B. 7-10 daysB. 7-10 days C. 2-4 weeksC. 2-4 weeks D. 4-6 weeksD. 4-6 weeks
    40. 40. Duration of Treatment for DiabeticDuration of Treatment for Diabetic Foot InfectionsFoot Infections
    41. 41. SummarySummary • The microbiology of DFIs is at least somewhatThe microbiology of DFIs is at least somewhat predictable, based on chronicity and antibioticpredictable, based on chronicity and antibiotic exposureexposure • Cultures should be obtained from the base of aCultures should be obtained from the base of a debrideddebrided ulcerulcer • Many cases of diabetic foot osteomyelitis canMany cases of diabetic foot osteomyelitis can be treated based on plain films alonebe treated based on plain films alone • All tests are fallible, but MRI offers the bestAll tests are fallible, but MRI offers the best combination of sensitivity and specificitycombination of sensitivity and specificity

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