Reply:
I welcome the publication of the investigation alluded to by the authors of the preceding letter. We clearly have a lot to learn with respect to the diagnosis of diabetic foot osteomyelitis (OM), and their proposed histopathologic classification system could prove to be an important step forward. I will especially consider whether their investigation examined the ability of pathologists to determine the difference between osteomyelitic and nonosteomyelitic bone, or whether it examined only the difference among different forms of OM after the primary diagnosis had been established.
I trust that the authors appreciate that we were attempting neither to establish nor to investigate a classification system in our study and that our categories were purposefully broad and simplified to highlight the clinical diagnoses that surgeons use to make patient care decisions. We agree with their concerns with respect to the “controversy … regarding the histologic patterns pathologists use as a reference,” which can be seen in our introductory paragraph when we stated that “there is no standardized definition or classification for OM with this analysis, and only a few clinical studies have attempted to define characteristics of bone samples affected by OM.” In addition, in our “Discussion” section, we suggested that the results “could be used in guiding future pathology department protocols for reaching a diagnosis from specific findings.”
I reject that interobserver variability was a specific limitation of our study, but rather believe it is a general and primary limitation of the histopathologic diagnosis of OM in the first place. I hope that most readers would reach this previously unappreciated conclusion.
Although it is possible that their proposed classification system will become validated and universally accepted among all pathologists, I will personally continue to use the extensive diagnostic criteria of the International Working Group of the Diabetic Foot (
1
) as opposed to a single diagnostic test.Reference
- Diabetic foot osteomyelitis: a progress report on diagnosis and a systematic review of treatment.Diabetes Metab Res Rev. 2008; 24: S145-S161
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Published online: June 12, 2013
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© 2013 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
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- Statistical Reliability of Bone Biopsy for the Diagnosis of Diabetic Foot OsteomyelitisThe Journal of Foot and Ankle SurgeryVol. 50Issue 6
- PreviewBone biopsy is often referred to as the reference standard for the diagnosis of diabetic foot osteomyelitis (OM), and it also serves as an important interventional tool with respect to diabetic foot infections and limb salvage. However, the phrase bone biopsy lacks a standardized definition, and the statistical reliability of the pathologic diagnosis has not been previously examined. The objective of the present study was to quantify the reliability of the histopathologic analysis of bone with respect to the diagnosis of diabetic foot OM.
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- Statistical Reliability of Bone Biopsy for the Diagnosis of Diabetic Foot OsteomyelitisThe Journal of Foot and Ankle SurgeryVol. 52Issue 5
- PreviewWe would like to comment on an article by Meyr et al (1) and describe our experience with diabetic foot osteomyelitis (2). We recently published a histopathologic classification of osteomyelitis according to the cell groups present and the histopathologic changes in the bone samples analyzed (2). We have shown that with the use of a perfectly defined theoretical framework, the interpretation of the data observed in the bone biopsy is no longer subjective and the interobserver variability decreases.
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