To the Editor.
—The excellent prospective study of Newman et al1 provides dramatic support for aggressive evaluation of diabetic foot ulcers, as most of these have underlying unsuspected osteomyelitis. However, their conclusions regarding indium leukocyte scanning and three-phase bone scanning merit further scrutiny.Abnormal tracer uptake in an infected soft-tissue ulcer is often difficult to distinguish from uptake in immediately adjacent underlying bone. Without orthogonal views, this becomes impossible. This study apparently analyzed indium leukocyte images acquired in the "dorsal and plantar positions" only, with no medial or lateral views. Their criteria for a "positive" indium leukocyte scan must be questioned in that they apparently did not discriminate focal soft tissue uptake from bone uptake. Their images shown in Fig 5 (p 1249, showing a round, black dot said to represent a metatarsal) are difficult to evaluate and one would wonder whether the decreasing activity on subsequent scans actually
Williams HT. Detection of Osteomyelitis Associated With Diabetic Foot Ulcers. JAMA. 1992;267(4):510. doi:10.1001/jama.1992.03480040058026