Meyr Andrew J, Seo Kyung, Khurana Jasvir S, Choksi Rachana, Chakraborty Baidarbhi
Clinical Associate Professor, Department of Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA.
Resident, Temple University Hospital Podiatric Surgical Residency Program, Temple University Hospital, Philadelphia, Pennsylvania.
J Foot Ankle Surg. 2018 Nov-Dec;57(6):1137-1139. doi: 10.1053/j.jfas.2018.05.010. Epub 2018 Sep 1.
Although bone biopsy has historically been considered the "gold standard" or "standard reference" for the diagnosis of diabetic foot osteomyelitis, some contemporary investigations have provided evidence against this as a single diagnostic test and in support of a combination of clinical, laboratory, and radiographic findings. The objective of this investigation was to measure the level of agreement between several commonly used forms of diagnostic testing for diabetic foot osteomyelitis. A retrospective chart review was performed of 50 consecutive patients admitted to a single tertiary healthcare center with the documented performance of 1) a clinical probe-to-bone test on hospital admission; 2) plain film radiographs prior to any surgical intervention; 3) magnetic resonance imaging prior to any surgical intervention; and an intraoperative excisional bone debridement performed, with samples sent for both 4) histologic analysis and 5) microbiologic analysis. A frequency count of agreement among these 5 tests was performed, and the interobserver (or inter-test) agreement was measured using the kappa statistic. We observed low levels of inter-test agreement between the 5 diagnostic tests (range 42.0%-62.0%), and levels of chance-corrected agreement were well below what would be considered appropriate for a "gold standard" or "standard reference." Levels of the kappa statistic ranged from 0.0 to 0.220, with most inter-test comparisons falling in the "poor agreement" and "slight agreement" interpretation ranges. The highest level of agreement occurred between the plain film radiographs and magnetic resonance imaging (62.0% agreement and kappa statistic of 0.220). Although it is likely that a combination of clinical, radiographic, and laboratory tests provides the best diagnostic approach for diabetic foot osteomyelitis, the data provided herein indicate that the tests themselves might have high intrinsic levels of unreliability and that the specific combination of tests that might be best used remains unclear.
尽管从历史上看，骨活检一直被视为诊断糖尿病足骨髓炎的“金标准”或“标准参考”，但一些当代研究提供了证据，反对将其作为单一诊断测试，并支持综合临床、实验室和影像学检查结果。本研究的目的是测量几种常用的糖尿病足骨髓炎诊断测试之间的一致性水平。对一家三级医疗中心连续收治的50例患者进行了回顾性病历审查，记录了以下检查的执行情况：1）入院时的临床探骨试验；2）任何手术干预前的X线平片；3）任何手术干预前的磁共振成像；以及进行术中切除性骨清创术，样本分别送去进行4）组织学分析和5）微生物学分析。对这5项检查之间的一致性进行了频数统计，并使用kappa统计量测量观察者间（或检查间）的一致性。我们观察到这5项诊断检查之间检查间一致性水平较低（范围为42.0%-62.0%），机会校正一致性水平远低于被认为适用于“金标准”或“标准参考”的水平。kappa统计量的范围为0.0至0.220，大多数检查间比较落在“一致性差”和“一致性一般”的解释范围内。X线平片和磁共振成像之间的一致性水平最高（一致性为62.0%，kappa统计量为0.220）。虽然临床、影像学和实验室检查相结合可能为糖尿病足骨髓炎提供最佳诊断方法，但本文提供的数据表明，这些检查本身可能具有较高的内在不可靠性，并且最佳使用的具体检查组合仍不清楚。
