Is 18 F-FDG PET-CT-guided geographic debridement superior to conventional debridement in appendicular chronic osteomyelitis? a retrospective comparative cohort study.

BACKGROUND

Determining the surgical extent of chronic osteomyelitis and fracture-related infection (FRI) remains challenging. Adequate resection margins prevent recurrence; however, no standardised preoperative tool objectively defines resection borders.

OBJECTIVE

To compare PET‑CT-guided surgical planning versus the local standard‑of‑care imaging pathway (predominantly plain radiographs, with selective CT or MRI in a minority of patients) for chronic limb osteomyelitis and FRI outcomes.

METHODS

Retrospective comparative cohort study of 126 patients treated 2019-2024. Group 1: 84 patients underwent 18 F-FDG PET-CT imaging and map-based geographic debridement. Group 2: 42 patients received surgery after local standard‑of‑care imaging pathway (predominantly plain radiographs, with selective CT or MRI).

PRIMARY OUTCOME: infection recurrence at 12 months. Multivariable logistic regression controlled for confounders.

RESULTS

PET-CT group achieved 3.6% recurrence versus 16.7% in the conventional group (p = 0.011), representing 78.5% relative risk reduction and a number-needed-to-treat of 8. Critically, the PET-CT cohort had significantly worse baseline complexity: 3.3-fold longer infection duration (43.1 vs. 13.1 months, p < 0.001) and 3.6-fold more prior surgeries (2.48 vs. 0.69, p < 0.001). Multivariable analysis confirmed PET-CT-guided surgery as an independent protective factor (OR 0.19, 95% CI 0.05-0.72, p = 0.015). PET-CT drew the resection margins in all cases, soft-tissue collections in 23.8%, and sequestra in 67.9%.

CONCLUSIONS

In this retrospective comparative study, PET-CT may enable objective, adequate geographic debridement, bridging radical and conservative approaches. Superior outcomes despite treating more complex infections may support PET-CT as a preoperative planning modality, demonstrating potential clinical and cost-effectiveness benefits. (Therapeutic study - retrospective comparative cohort).

LEVEL OF EVIDENCE: III (Therapeutic study - retrospective comparative cohort).