A Structured Diagnostic Pathway for Diabetic Foot Osteomyelitis: Optimising MRI Use through Clinical and Plain Radiographic Assessment

Background: In current clinical practice, MRI is widely regarded as the preferred non-invasive modality for early detection of osteomyelitis and associated soft-tissue abnormalities. However, due to high costs and limited availability, MRI use is often limited. Objective: To evaluate the current practice of MRI utilization and to assess its diagnostic yield in patients with suspected diabetic foot osteomyelitis (DFO). Methods: We conducted a retrospective cross-sectional analysis of 50 patients who underwent foot MRI for suspected DFO at the University Hospitals of Liverpool Group between May and November 2024. Demographic data, clinical documentation, and imaging findings from plain radiographs and MRI were reviewed using the Clinical Radiology Information System (CRIS) and Carestream PACS. Results: The cohort comprised 80% males and 20% females, with a mean age of 65 years. Foot ulcers were documented in 94% of cases, but the exact site was specified in only 63%. Plain radiographs were performed in 98% of patients, with osteomyelitis reported in 32%, suspected in 4%, and negative in 58%. Among radiographically negative cases, repeat X-ray was advised in 96%, but MRI was recommended in only 12%. MRI confirmed osteomyelitis in 62% of cases, though only 28% of reports described the extent of disease. In total, 52% of MRIconfirmed cases had corresponding findings on plain radiographs, 35% did not, and 13% lacked separate plain film reports. Conclusion: While MRI offers excellent sensitivity, it may be unnecessary when clinical assessment and plain radiography are concordant.