Diagnostic Value and Integrated Threshold of ESR for Diabetic Foot Osteomyelitis: A systemic review and Meta-Analysis

Lulu LiuYukun TaoDa Zhang^*Jingzheng HouGuangxin ZhouMaolin Tian

• People's Liberation Army Air Force Special Medical Center, Beijing, China

Background: Diabetic foot osteomyelitis (DFO) is a severe complication of diabetic foot infections (DFI). Early and accurate diagnosis is crucial for improving patient outcomes. The erythrocyte sedimentation rate (ESR), a commonly used inflammatory marker, has been controversial regarding its diagnostic value and optimal cutoff values in DFO. Objective: This study aims to conduct a systematic review and meta-analysis to comprehensively evaluate the diagnostic efficacy of ESR for DFO and to determine an optimal pooled cutoff value for the marker. Methods: A systematic search of PubMed, EMBASE, Cochrane Library, OVID, and the Wanfang database was conducted for literature related to ESR in the diagnosis of DFO, with the search period extending through March 2025. The Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool was applied for quality evaluation of the included studies. Statistical analyses were performed using Stata 18.0 to generate hierarchical summary receiver operating characteristic (HSROC) curves and forest plots for assessing the diagnostic performance of ESR in DFO. To determine the optimal composite cutoff value of ESR for diagnosing DFO, a different random intercepts and common random slope (DICS) model was implemented using R4.5.0. Subsequently, a Generalized Linear Mixed Model (GLMM) was constructed to predict the corresponding sensitivity and specificity at the ESR threshold of 70 mm/h. Results: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 12 studies with a total of 1,674 subjects were included. The HSROC model revealed that the area under the curve (AUC) for ESR in diagnosing DFO was 0.71, with sensitivity and specificity values of 0.76 and 0.73, respectively. The DICS model identified an optimal pooled cutoff value for ESR at 51.6 mm/h, with corresponding sensitivity and specificity values of 0.80 and 0.67, respectively. Using the GLM model, an ESR cutoff of 70 mm/h yielded sensitivity and specificity of 0.61 and 0.83, respectively. Conclusion: ESR demonstrates moderate diagnostic efficacy in the identification of DFO. Based on our findings, we recommend the optimal pooled cutoff value for ESR is 51.6 mm/h, as a preliminary screening tool in the diagnostic workup of DFO.