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Combination of Plain X-ray and Probe-to-Bone for Diagnosing Diabetic Foot Osteomyelitis
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  • Update Date: 25 Aug 2025
Playlist
  • diabetic foot
  • diabetic foot ulcer
  • diabetic foot osteomyelitis
  • probe-to-bone test
  • plain X-ray
Chapter
00:12
Introduction
00:54
Methodology
01:48
Results
02:28
Clinical Implications
03:04
Future Research
03:34
Conclusion
Video Introduction

This video is adapted from 10.3390/jcm12165369

A systematic review and meta-analysis was conducted to assess the diagnostic accuracy of the combination of plain X-ray and probe-to-bone (PTB) test for diagnosing diabetic foot osteomyelitis (DFO). This systematic review has been registered in PROSPERO (a prospective international register of systematic reviews; identification code CRD42023436757). A literature search was conducted for each test separately along with a third search for their combination. A total of 18 articles were found and divided into three groups for separate analysis and comparison. All selected studies were evaluated using STROBE guidelines to assess the quality of reporting for observational studies. Meta-DiSc software was used to analyze the collected data. Concerning the diagnostic accuracy variables for each case, the pooled sensitivity (SEN) was higher for the combination of PTB and plain X-ray [0.94 (PTB + X-ray) vs. 0.91 (PTB) vs. 0.76 (X-ray)], as was the diagnostic odds ratio (DOR) (82.212 (PTB + X-ray) vs. 57.444 (PTB) vs. 4.897 (X-ray)). The specificity (SPE) and positive likelihood ratio (LR+) were equally satisfactory for the diagnostic combination but somewhat lower than for PTB alone (SPE: 0.83 (PTB + X-ray) vs. 0.86 (PTB) vs. 0.76 (X-ray); LR+: 5.684 (PTB + X-ray) vs. 6.344 (PTB) vs. 1.969 (X-ray)). The combination of PTB and plain X-ray showed high diagnostic accuracy comparable to that of MRI and histopathology diagnosis (the gold standard), so it could be considered useful for the diagnosis of DFO. In addition, this diagnostic combination is accessible and inexpensive but requires training and experience to correctly interpret the results. Therefore, recommendations for this technique should be included in the context of specialized units with a high prevalence of DFO [1][2][3][4][5][6][7][8][9][10][11][12].

References
  1. Álvaro-Afonso, F.J.; Lázaro-Martínez, J.L.; Aragón-Sánchez, J.; García-Morales, E.; Cecilia-Matilla, A.; Beneit-Montesinos, J.V.Interobserver and intraobserver reproducibility of plain X-rays in the diagnosis of diabetic foot osteomyelitis. Int. J. Low. Extrem.Wounds 2013, 12, 12–15
  2. Grayson, M.L.; Gibbons, G.W.; Balogh, K.; Levin, E.; Karchmer, A.W. Probing to bone in infected pedal ulcers. A clinical sign of underlying osteomyelitis in diabetic patients. JAMA 1995, 273, 721–723. - Segall, G.M.; Nino-Murcia, M.; Jacobs, T.; Chang, K. The role of bone scan and radiography in the diagnostic evaluation of suspected pedal osteomyelitis. Clin. Nucl. Med. 1989, 14, 255–260. 
  3. Aragon-Sanchez, J.; Lipsky, B.A.; Lazaro-Martinez, J.L. Diagnosing diabetic foot osteomyelitis: Is the combination of probe-to-bone test and plain radiography sufficient for high-risk inpatients? Diabet. Med. 2011, 28, 191–194.
  4. Lavery, L.A.; Armstrong, D.G.; Peters, E.J.; Lipsky, B.A. Probe-to-bone test for diagnosing diabetic foot osteomyelitis: Reliable or relic? Diabetes Care 2007, 30, 270–274
  5. Morales Lozano, R.; González Fernández, M.L.; Martinez Hernández, D.; Beneit Montesinos, J.V.; Guisado Jiménez, S.; Gonzalez Jurado, M.A. Validating the probe-to-bone test and other tests for diagnosing chronic osteomyelitis in the diabetic foot. Diabetes Care 2010, 33, 2140–2145
  6. Weinstein, D.; Wang, A.; Chambers, R.; Stewart, C.A.; Motz, H.A. Evaluation of magnetic resonance imaging in the diagnosis of osteomyelitis in diabetic foot infections. Foot Ankle 1993, 14, 18–22
  7. Blume, P.A.; Dey, H.M.; Daley, L.J.; Arrighi, J.A.; Soufer, R.; Gorecki, G.A. Diagnosis of pedal osteomyelitis with Tc-99m HMPAO labeled leukocytes. J. Foot Ankle Surg. 1997, 36, 120–126
  8. Enderle, M.D.; Coerper, S.; Schweizer, H.P.; Kopp, A.E.; Thelen, M.H.; Meisner, C.; Pressler, H.; Becker, H.D.; Claussen, C.; Häring, H.U.; et al. Correlation of imaging techniques to histopathology in patients with diabetic foot syndrome and clinical suspicion of chronic osteomyelitis. The role of high-resolution ultrasound. Diabetes Care 1999, 22, 294–299
  9. Álvaro-Afonso, F.J.; Lázaro-Martínez, J.L.; García-Morales, E.; García-Álvarez, Y.; Sanz-Corbalán, I.; Molines-Barroso, R.J. Cortical disruption is the most reliable and accurate plain radiographic sign in the diagnosis of diabetic foot osteomyelitis. Diabet. Med. 2019, 36, 258–259
  10. Álvaro-Afonso, F.J.; Lázaro-Martínez, J.L.; Aragón-Sánchez, F.J.; García-Morales, E.; Carabantes-Alarcón, D.; Molines-Barroso, R.J.Does the location of the ulcer affect the interpretation of the probe-to-bone test in the diagnosis of osteomyelitis in diabetic foot ulcers? Diabet. Med. 2014, 31, 112–113
  11. Álvaro-Afonso,F.J.; Lázaro-Martínez, J.L.; Aragón-Sánchez, J.; García-Morales, E.; Cecilia-Matilla, A.; Beneit-Montesinos, J.V. Interobserver and intraobserver reproducibility of plain X-rays in the diagnosis of diabetic foot osteomyelitis. Int. J. Low. Extrem.Wounds 2013, 12, 12–15
  12. Álvaro-Afonso, F.J.; Lázaro-Martínez, J.L.; Aragón-Sánchez, J.; García-Morales, E.; García-Álvarez, Y.; Molines-Barroso, R.J.Inter-observer reproducibility of diagnosis of diabetic foot osteomyelitis based on a combination of probe-to-bone test and simple radiography. Diabetes Res. Clin. Pract. 2014, 105, e3–e5
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Francisco Javier, A.; Calvo-Wright, M.D.M.; López-Moral, M.; García-Álvarez, Y.; García-Morales, E.; Lázaro-Martínez, J.L. Combination of Plain X-ray and Probe-to-Bone for Diagnosing Diabetic Foot Osteomyelitis. Encyclopedia. Available online: https://encyclopedia.pub/video/video_detail/1654 (accessed on 05 December 2025).
Francisco Javier A, Calvo-Wright MDM, López-Moral M, García-Álvarez Y, García-Morales E, Lázaro-Martínez JL. Combination of Plain X-ray and Probe-to-Bone for Diagnosing Diabetic Foot Osteomyelitis. Encyclopedia. Available at: https://encyclopedia.pub/video/video_detail/1654. Accessed December 05, 2025.
Francisco Javier, Alvaro-Afonso, María Del Mar Calvo-Wright, Mateo López-Moral, Yolanda García-Álvarez, Esther García-Morales, José Luis Lázaro-Martínez. "Combination of Plain X-ray and Probe-to-Bone for Diagnosing Diabetic Foot Osteomyelitis" Encyclopedia, https://encyclopedia.pub/video/video_detail/1654 (accessed December 05, 2025).
Francisco Javier, A., Calvo-Wright, M.D.M., López-Moral, M., García-Álvarez, Y., García-Morales, E., & Lázaro-Martínez, J.L. (2025, July 14). Combination of Plain X-ray and Probe-to-Bone for Diagnosing Diabetic Foot Osteomyelitis. In Encyclopedia. https://encyclopedia.pub/video/video_detail/1654
Francisco Javier, Alvaro-Afonso, et al. "Combination of Plain X-ray and Probe-to-Bone for Diagnosing Diabetic Foot Osteomyelitis." Encyclopedia. Web. 14 July, 2025.
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