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Valero-Martínez C, Castillo-Morales V, Gómez-León N, Hernández-Pérez I, Vicente-Rabaneda EF, Uriarte M, Castañeda S. Application of Nuclear Medicine Techniques in Musculoskeletal Infection: Current Trends and Future Prospects. J Clin Med 2024; 13:1058. [PMID: 38398371 PMCID: PMC10889833 DOI: 10.3390/jcm13041058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 02/05/2024] [Accepted: 02/08/2024] [Indexed: 02/25/2024] Open
Abstract
Nuclear medicine has become an indispensable discipline in the diagnosis and management of musculoskeletal infections. Radionuclide tests serve as a valuable diagnostic tool for patients suspected of having osteomyelitis, spondylodiscitis, or prosthetic joint infections. The choice of the most suitable imaging modality depends on various factors, including the affected area, potential extra osseous involvement, or the impact of previous bone/joint conditions. This review provides an update on the use of conventional radionuclide imaging tests and recent advancements in fusion imaging scans for the differential diagnosis of musculoskeletal infections. Furthermore, it examines the role of radionuclide scans in monitoring treatment responses and explores current trends in their application. We anticipate that this update will be of significant interest to internists, rheumatologists, radiologists, orthopedic surgeons, rehabilitation physicians, and other specialists involved in musculoskeletal pathology.
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Affiliation(s)
- Cristina Valero-Martínez
- Rheumatology Service, Hospital Universitario de La Princesa, IIS-Princesa, 28006 Madrid, Spain; (C.V.-M.); (E.F.V.-R.); (M.U.)
| | - Valentina Castillo-Morales
- Nuclear Medicine Service, Hospital Universitario de La Princesa, IIS-Princesa, 28006 Madrid, Spain; (V.C.-M.); (I.H.-P.)
| | - Nieves Gómez-León
- Radiology Service, Hospital Universitario de La Princesa, IIS-Princesa, 28006 Madrid, Spain;
| | - Isabel Hernández-Pérez
- Nuclear Medicine Service, Hospital Universitario de La Princesa, IIS-Princesa, 28006 Madrid, Spain; (V.C.-M.); (I.H.-P.)
| | - Esther F. Vicente-Rabaneda
- Rheumatology Service, Hospital Universitario de La Princesa, IIS-Princesa, 28006 Madrid, Spain; (C.V.-M.); (E.F.V.-R.); (M.U.)
| | - Miren Uriarte
- Rheumatology Service, Hospital Universitario de La Princesa, IIS-Princesa, 28006 Madrid, Spain; (C.V.-M.); (E.F.V.-R.); (M.U.)
| | - Santos Castañeda
- Rheumatology Service, Hospital Universitario de La Princesa, IIS-Princesa, 28006 Madrid, Spain; (C.V.-M.); (E.F.V.-R.); (M.U.)
- Cathedra UAM-Roche, EPID-Future, Department of Medicine, Universidad Autónoma de Madrid (UAM), 28006 Madrid, Spain
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Weissman BN, Palestro CJ, Fox MG, Bell AM, Blankenbaker DG, Frick MA, Jawetz ST, Kuo PH, Said N, Stensby JD, Subhas N, Tynus KM, Walker EA, Kransdorf MJ. ACR Appropriateness Criteria® Imaging After Total Hip Arthroplasty. J Am Coll Radiol 2023; 20:S413-S432. [PMID: 38040462 DOI: 10.1016/j.jacr.2023.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/22/2023] [Indexed: 12/03/2023]
Abstract
This article reviews evidence for performing various imaging studies in patients with total hip prostheses. Routine follow-up is generally performed with radiography. Radiographs are also usually the initial imaging modality for patients with symptoms related to the prosthesis. Following acute injury with pain, noncontrast CT may add information to radiographic examination regarding the presence and location of a fracture, component stability, and bone stock. Image-guided joint aspiration, noncontrast MRI, and white blood cell scan and sulfur colloid scan of the hip, are usually appropriate studies for patients suspected of having periprosthetic infection. For evaluation of component loosening, wear, and/or osteolysis, noncontrast CT or MRI are usually appropriate studies. Noncontrast MRI is usually appropriate for identifying adverse reaction to metal debris related to metal-on-metal articulations. For assessing patients after hip arthroplasty, who have trochanteric pain and nondiagnostic radiographs, ultrasound, or MRI are usually appropriate studies. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | | | | | - Angela M Bell
- Rush University Medical Center, Chicago, Illinois; American College of Physicians
| | - Donna G Blankenbaker
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | | | - Phillip H Kuo
- University of Arizona, Tucson, Arizona; Commission on Nuclear Medicine and Molecular Imaging
| | - Nicholas Said
- Duke University Medical Center, Durham, North Carolina
| | | | | | - Katherine M Tynus
- Northwestern Memorial Hospital, Chicago, Illinois; American College of Physicians
| | - Eric A Walker
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania; Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Hua H, Liu J. Diagnostic accuracy of positron emission tomography/computerized tomography for periprosthetic joint infection of hip: systematic review and meta-analysis. J Orthop Surg Res 2023; 18:640. [PMID: 37644493 PMCID: PMC10466775 DOI: 10.1186/s13018-023-04061-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/31/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND American Academy of Orthopaedic Surgeons (AAOS) has provided the guidelines for diagnosing a patient with periprosthetic joint infection including the use of positron emission tomography/computed tomography (PET/CT). Systematic evidence focussing on periprosthetic joint infection (PJI) of hip is limited, which also contains limited number of studies. Hence, the current study aims to perform a pooled analysis of all studies that have assessed the diagnostic accuracy of PET/CT for PJI of hip. METHODS Searches were done in PubMed Central, EMBASE, MEDLINE, SCOPUS and Cochrane library until December 2022. Meta-analysis was carried out using random-effects model. With 95% confidence intervals (CIs), pooled sensitivity and specificity were reported. RESULTS Twenty-six studies met the inclusion criteria. The pooled sensitivity of PET/CT was 89% (95% CI 84-93%), while the pooled specificity was 86% (95% CI 79-91%). The AUROC was 0.94 (95% CI 0.72-0.99). There was statistically significant heterogeneity (p < 0.001) with I2 value of 96%. The diagnostic odds ratio was 52 (95% CI 26-106). Likelihood ratio positive was 6.5 (95% CI 4.1-10.3) and negative was 0.13 (95% CI 0.08-0.19). CONCLUSION Our study found that PET/CT was found to have higher level of accuracy in terms of sensitivity and specificity. Further large-scale research can help to find answers for such questions and provide final conclusive evidence on the inclusion of the imaging modality into the routine clinical practice guidelines for suspected periprosthetic joint infection patients.
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Affiliation(s)
- Hongning Hua
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030032, China
| | - Jinwen Liu
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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Palestro CJ. Molecular Imaging of Periprosthetic Joint Infections. Semin Nucl Med 2023; 53:167-174. [PMID: 36496268 DOI: 10.1053/j.semnuclmed.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 11/29/2022] [Indexed: 12/14/2022]
Abstract
Infection is an infrequent complication of lower extremity prosthetic joint surgery. Approximately one third develop within 3 months (early), another third within 1 year (delayed), and the remainder more than 1 year (late) after surgery. The diagnosis of periprosthetic joint infection is not always straightforward. Pain, the most common symptom, is present in 90%-100% of patients. The presence of fever is more variable, ranging from less than 5% to more than 40% of patients with infection. Erythema and joint swelling are often present in acute infections, but are less common in chronic infections. Erythrocyte sedimentation rate, C-reactive protein and interleukin-6 levels are useful "rule out" tests, while peripheral blood leukocyte count and serum tumor necrosis factor α are not helpful. The diagnosis of periprosthetic joint infection often requires a combination of blood, synovial fluid, and tissue sample tests, as well as imaging. Plain radiographs lack sensitivity and specificity. Molecular imaging is useful for evaluating painful joint replacements. Bone scintigraphy is most useful as a screening test. If it is negative then infection and aseptic loosening are unlikely. Combined labeled leukocyte/bone marrow imaging is a very specific test for diagnosing lower extremity joint arthroplasty infection; sensitivity is more variable. Despite more than two decades of investigation, there still is no consensus on the value of 18F-FDG for diagnosing periprosthetic joint infection. Differing test probabilities, an inability to discriminate between infection and inflammation secondary to physiologic reactions, and lack of standardized interpretative criteria are obstacles to incorporating 18F-FDG into the routine diagnostic imaging workup of periprosthetic joint infection. Preliminary results for gallium-68 citrate, fluorine-18, and technetium-99m labeled antimicrobial fragments are encouraging but no large scale trials with these agents have been conducted. Limited data suggest that labeled leukocyte/bone marrow SPECT/CT and 18F-FDG-PET/CT are specific but not sensitive for diagnosing periprosthetic infection of shoulder arthroplasties. There are minimal data on molecular imaging for monitoring treatment response in periprosthetic infections.
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Wang Y, Yuan L, Du Y, Liu H, Li Q, Chang Y, Shi Y, Wang Y, Meng X, Zhou Y, Yao S, Tian J. Performance characteristics of 18F-fluorodeoxyglucose in non-infected hip replacement. Front Med (Lausanne) 2023; 9:1043812. [PMID: 36698792 PMCID: PMC9870722 DOI: 10.3389/fmed.2022.1043812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/13/2022] [Indexed: 01/07/2023] Open
Abstract
Purpose The aim of this study was to retrospectively analyze 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET)/ computed tomography (CT) images of non-infected hip arthroplasty patients and summarize findings that may be useful for clinical practice. Methods 18F-FDG PET/CT images of non-infected hip arthroplasty patients were collected from September 2009 to August 2021. The region of interest was independently delineated by two physicians and maximum standardized uptake values (SUVmax) were recorded and compared. Serologic data were also collected and the correlation between SUVmax and serologic parameters was analyzed, while the images were classified based on the 18F-FDG uptake pattern in the images using the diagnostic criteria proposed by Reinartz et al. (9). The interval between hip replacement and PET/CT was classified by year and the characteristics of the two groups were compared. The images of patients who underwent PET/CT multiple times were analyzed dynamically. Results A total of 121 examinations were included; six patients underwent PET/CT twice and two patients had three scans. There were no significant correlations between SUVmax and serologic results. The interobserver agreement between the two physicians in the classification according to the criteria of Reinartz et al. (9) was 0.957 (P < 0.005). Although there was non-specific uptake in cases with an arthroplasty-to-PET/CT interval this was non-significant. Additionally, 18F-FDG showed potential utility for dynamic observation of the condition of the hip. Conclusion SUVmax provided information independent of serologic results, meanwhile 18F-FDG showed potential applicability to the dynamic monitoring of hip arthroplasty-related diseases. However, the presence of blood vessels and muscles affected image interpretation and the specificity of 18F-FDG was not optimal. A more specific radionuclide is needed to maximize the benefits of using PET/CT for the assessment of periprosthetic joint infection (PJI).
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Affiliation(s)
- Yiqun Wang
- Department of Nuclear Medicine, The First Medical Centre, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China,Beijing Key Laboratory of Sports Injuries, Department of Sports Medicine, Institute of Sports Medicine of Peking University, Peking University Third Hospital, Beijing, China
| | - Lulu Yuan
- Department of Nuclear Medicine, The First Medical Centre, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Yinqiao Du
- Department of Orthopedics Surgery, The First Medical Center, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China,Department of Orthopedics Surgery, The Fourth Medical Centre, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Honghong Liu
- Department of Nuclear Medicine, The First Medical Centre, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Qingxiao Li
- Department of Nuclear Medicine, The First Medical Centre, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Yan Chang
- Department of Nuclear Medicine, The First Medical Centre, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China,Yan Chang,
| | - Yuanyuan Shi
- Beijing Key Laboratory of Sports Injuries, Department of Sports Medicine, Institute of Sports Medicine of Peking University, Peking University Third Hospital, Beijing, China
| | - Yanmei Wang
- General Electric (GE) Healthcare China, Shanghai, China
| | - Xiaolin Meng
- Department of Nuclear Medicine, The First Medical Centre, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Yonggang Zhou
- Department of Orthopedics Surgery, The First Medical Center, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China,Department of Orthopedics Surgery, The Fourth Medical Centre, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China,*Correspondence: Yonggang Zhou,
| | - Shulin Yao
- Department of Nuclear Medicine, The First Medical Centre, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China,Shulin Yao,
| | - Jiahe Tian
- Department of Nuclear Medicine, The First Medical Centre, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China,Jiahe Tian,
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Boero M, Allocca M, Pisu N, Sanna S, Ruggiero A, Pung BLJ, Margotti S, Dessì G. Management of periprosthetic knee joint infections: focus on the role of Nuclear Medicine (v2). Orthop Rev (Pavia) 2022; 14:39646. [PMID: 36381502 PMCID: PMC9662607 DOI: 10.52965/001c.39646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Abstract
BACKGROUND When faced with a painful knee replacement, ruling out infection is mandatory to set the correct therapeutic approach. However, it is not always easy, especially in subclinical/chronic infections. A multidisciplinary approach is necessary to assess in the most correct way each case of suspected periprosthetic knee joint infection. This review explores the role of nuclear medicine investigations in the management of periprosthetic knee infections and their proper use within a multidisciplinary pathway. METHODS A PubMed search was conducted selecting studies from the past 10 years. RESULTS Triphasic bone scintigraphy has high sensitivity (93%) but poor specificity (56%) for periprosthetic joint infections of the knee, with a high negative predictive value (NPV), ranging from 96% to 100%. Consequently, a negative bone scan is useful in ruling out infection. In contrast, radiolabeled leukocyte scintigraphy is characterized by a sensitivity of 85.7-93%, specificity of 93.6-100%, diagnostic accuracy of 92.6-98%, NPV of 93-97.8%, and positive predictive value (PPV) of 66.7-100%. By adding a tomographic acquisition with hybrid single-photon emission computed tomography combined with computed tomography technique (SPECT/CT), the diagnostic accuracy increases. Because 18F-fluorodeoxyglucose (FDG) accumulates at both sites of inflammation and infection, FDG positron emission tomography (PET/CT) shows low specificity. CONCLUSIONS A common decision-making process in the diagnosis of periprosthetic joint infection is not yet validated and multidisciplinary integration is mandatory. In this context, nuclear medicine can contribute decisively.
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Affiliation(s)
| | | | - Nicola Pisu
- Nuclear Medicine, Brotzu Hospital, Cagliari (Italy)
| | - Silvia Sanna
- Nuclear Medicine, Brotzu Hospital, Cagliari (Italy)
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Rachh SS, Basu S, Alavi A. Fluorodeoxyglucose PET/Computed Tomography in Evaluation of Prosthetic Joints and Diabetic Foot: A Comparative Perspective with Other Functional Imaging Modalities. PET Clin 2022; 17:517-531. [PMID: 35717105 DOI: 10.1016/j.cpet.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Infection imaging has been an important part of nuclear medicine practice. Infections in prosthetic joints and diabetic foot are associated with devastating complications, posing substantial challenge for both diagnosis and overall management. For many years, conventional nuclear medicine techniques have been used to frame a painful joint arthroplasty or diabetic foot infection. The various functional nuclear imaging modalities used include labeled leukocyte imaging, combined leukocyte-marrow scintigraphy, antigranulocyte antibody scintigraphy, 3-phase bone scintigraphy, and fluorodeoxyglucose PET/computed tomography, yet no single method has proved to be highly sensitive and specific and at the same time safe, simple, and time-effective.
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Affiliation(s)
- Swati Sodagar Rachh
- Department of Nuclear Medicie, Gujarat Cancer & Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad 380016, India; Radiation Medicine Centre (B.A.R.C), Tata Memorial Centre Annexe, Parel, Mumbai, India
| | - Sandip Basu
- Radiation Medicine Centre (B.A.R.C), Tata Memorial Centre Annexe, Parel, Mumbai, India; Homi Bhabha National Institute, Mumbai, India.
| | - Abass Alavi
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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8
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Hu M, Chen G, Luo L, Shang L. A Systematic Review and Meta-Analysis on the Accuracy of Fluorodeoxyglucose Positron Emission Tomography/ Computerized Tomography for Diagnosing Periprosthetic Joint Infections. Front Surg 2022; 9:698781. [PMID: 35722526 PMCID: PMC9198456 DOI: 10.3389/fsurg.2022.698781] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/17/2022] [Indexed: 11/21/2022] Open
Abstract
Objective Fluorodeoxyglucose Positron emission tomography/computerized tomography (FDG PET/CT) has become popular for diagnosing periprosthetic joint infections (PJI). However, the diagnostic accuracy for this technique has varied from report to report. This meta-analysis was performed to assess the accuracy of FDG PET/CT for PJI diagnosis. Material and Methods We conducted a systematic search of online academic databases for all studies reporting the diagnostic accuracy of FDG PET/CT for PJI. Meta-analysis was performed using STATA software. Results 23 studies, containing data on 1,437 patients, met inclusion criteria. Pooled sensitivity and specificity of FDG PET/CT for diagnosing PJI were 85% (95% CI, 76%, 91%) and 86% (95% CI, 78%, 91%), respectively with an AUC of 0.92. LRP was 6.1 (95% CI, 3.8, 9.7) and LRN was 0.17 (0.11, 0.28), indicating that FDG PET/CT cannot be used for confirmation or exclusion of PJI. There was significant inter-study heterogeneity, but no significant publication bias was noted. Conclusions Our study found that FDG PET/CT has an important role as a diagnostic tool for PJI with high sensitivity and specificity. Further studies exploring its accuracy in different PJI locations remain necessary.
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9
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Ottink KD, Gelderman SJ, Wouthuyzen-Bakker M, Ploegmakers JJW, Glaudemans AWJM, Jutte PC. Nuclear imaging does not have clear added value in patients with low a priori chance of periprosthetic joint infection. A retrospective single-center experience. J Bone Jt Infect 2022; 7:1-9. [PMID: 35047347 PMCID: PMC8759077 DOI: 10.5194/jbji-7-1-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 12/05/2021] [Indexed: 11/21/2022] Open
Abstract
Background: A low-grade periprosthetic joint infection (PJI) may present without
specific symptoms, and its diagnosis remains a challenge. Three-phase bone scintigraphy (TPBS) and white blood cell (WBC) scintigraphy are
incorporated into recently introduced diagnostic criteria for PJI, but their exact value in diagnosing low-grade PJI in patients with nonspecific
symptoms remains unclear.
Methods:
In this retrospective study, we evaluated patients with a prosthetic joint
of the hip or knee who underwent TPBS and/or WBC scintigraphy between 2009 and 2016 because of nonspecific symptoms. We reviewed and calculated
diagnostic accuracy of the TPBS and/or WBC scintigraphy to diagnose or
exclude PJI. PJI was defined based on multiple cultures obtained during
revision surgery. In patients who did not undergo revision surgery, PJI was
ruled out by clinical follow-up of at least 2 years absent of clinical signs of infection based on MSIS 2011 criteria.
Results:
A total of 373 patients were evaluated, including 340 TPBSs and 142 WBC scintigraphies. Thirteen patients (3.5 %) were diagnosed with a PJI. TPBS sensitivity, specificity, and positive and negative predictive values (PPV, NPV) were 71 %, 65 %, 8 % and 98 %, respectively. Thirty-five percent of TPBS showed
increased uptake. Stratification for time intervals between the index
arthroplasty and the onset of symptoms did not alter its diagnostic
accuracy. WBC scintigraphy sensitivity, specificity, PPV and NPV were 30 %, 90 %, 25 % and 94 %, respectively.
Conclusion:
Nuclear imaging does not have clear added value in patients with low a
priori chance of periprosthetic joint infection.
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Affiliation(s)
- Karsten D Ottink
- Department of Orthopaedics, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Stefan J Gelderman
- Department of Orthopaedics, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands.,Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Joris J W Ploegmakers
- Department of Orthopaedics, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Andor W J M Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Paul C Jutte
- Department of Orthopaedics, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
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Abstract
» A 3-phase bone scan is a potential first-line nuclear medicine study for pain after total joint arthroplasty (TJA) when there is concern for periprosthetic joint infection or aseptic loosening. » In patients who have a positive bone scintigraphy result and suspected infection of the joint, but where aspiration or other studies are inconclusive, labeled leukocyte scintigraphy with bone marrow imaging may be of benefit. » Magnetic resonance imaging (MRI), while not a nuclear medicine study, also shows promise and has the advantage of providing information about the soft tissues around a total joint replacement. » Radiotracer uptake patterns in scintigraphy are affected by the prosthesis (total knee arthroplasty [TKA] versus total hip arthroplasty [THA]) and the use of cement. » Nuclear medicine scans may be ordered 1 year postoperatively but may have positive findings that are due to normal physiologic bone remodeling. Nuclear studies may be falsely positive for up to 2 years after TJA. » Single-photon emission computed tomography (SPECT) combined with computed tomography (CT) (SPECT/CT), fluorine-18 fluorodeoxyglucose (18F-FDG) positron emission tomography (PET)/CT, and MRI show promise; however, more studies are needed to better define their role in the diagnostic workup of pain after TJA.
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Affiliation(s)
- John M Pinski
- Department of Orthopedic Surgery, Tufts Medical Center, Boston, Massachusetts
| | - Antonia F Chen
- Department of Orthopedic Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Daniel M Estok
- Department of Orthopedic Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Joseph J Kavolus
- Department of Orthopedic Surgery, Tufts Medical Center, Boston, Massachusetts
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11
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Romanò CL, Petrosillo N, Argento G, Sconfienza LM, Treglia G, Alavi A, Glaudemans AW, Gheysens O, Maes A, Lauri C, Palestro CJ, Signore A. The Role of Imaging Techniques to Define a Peri-Prosthetic Hip and Knee Joint Infection: Multidisciplinary Consensus Statements. J Clin Med 2020; 9:jcm9082548. [PMID: 32781651 PMCID: PMC7466174 DOI: 10.3390/jcm9082548] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/20/2020] [Accepted: 08/03/2020] [Indexed: 02/07/2023] Open
Abstract
Diagnosing a peri-prosthetic joint infection (PJI) remains challenging despite the availability of a variety of clinical signs, serum and synovial markers, imaging techniques, microbiological and histological findings. Moreover, the one and only true definition of PJI does not exist, which is reflected by the existence of at least six different definitions by independent societies. These definitions are composed of major and minor criteria for defining a PJI, but most of them do not include imaging techniques. This paper highlights the pros and cons of available imaging techniques—X-ray, ultrasound, computed tomography (CT), Magnetic Resonance Imaging (MRI), bone scintigraphy, white blood cell scintigraphy (WBC), anti-granulocyte scintigraphy, and fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT), discusses the added value of hybrid camera systems—single photon emission tomography/computed tomography (SPECT/CT), PET/CT and PET/MRI and reports consensus answers on important clinical questions that were discussed during the Third European Congress on Inflammation/Infection Imaging in Rome, December 2019.
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Affiliation(s)
- Carlo Luca Romanò
- Gruppo di Studio SIOT Infezioni-Clinica San Gaudenzio-Novara-Gruppo Policlinico di Monza, University of Milan, 20100 Milan, Italy;
| | - Nicola Petrosillo
- Clinical and Research Department for Infectious Diseases, National Institute for Infective Diseases “L. Spallanzani”, 00144 Rome, Italy;
| | | | - Luca Maria Sconfienza
- IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy;
- Department of Biomedical Sciences for Health, University of Milan, 20123 Milan, Italy
| | - Giorgio Treglia
- Nuclear Medicine and PET/CT Center, Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale Via Lugano 4F, CH-6500 Bellinzona, Switzerland;
- Department of Nuclear Medicine and Molecular Imaging, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Abass Alavi
- Division of Nuclear Medicine, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA 1904, USA;
| | - Andor W.J.M. Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands;
| | - Olivier Gheysens
- Department of Nuclear Medicine, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium;
| | - Alex Maes
- Department of Nuclear Medicine, AZ Groeninge, Kortrijk Belgium and Department of Imaging and Pathology @ KULAK, KU Leuven campus Kulak, 8500 Kortrijk, Belgium;
| | - Chiara Lauri
- Nuclear Medicine Unit Department of Medical-Surgical Sciences and of Translational Medicine, Faculty of Medicine and Psychology, “Sapienza” University of Rome, 00161 Rome, Italy;
| | - Christopher J. Palestro
- Department of Radiology Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA;
| | - Alberto Signore
- Nuclear Medicine Unit Department of Medical-Surgical Sciences and of Translational Medicine, Faculty of Medicine and Psychology, “Sapienza” University of Rome, 00161 Rome, Italy;
- Correspondence:
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Molecular Imaging of Inflammation and Infection. Clin Nucl Med 2020. [DOI: 10.1007/978-3-030-39457-8_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kiran M, Donnelly TD, Armstrong C, Kapoor B, Kumar G, Peter V. Diagnostic utility of fluorodeoxyglucose positron emission tomography in prosthetic joint infection based on MSIS criteria. Bone Joint J 2019; 101-B:910-914. [PMID: 31362552 DOI: 10.1302/0301-620x.101b8.bjj-2018-0929.r2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Prosthetic joint infection (PJI) and aseptic loosening in total hip arthroplasty (THA) can present with pain and osteolysis. The Musculoskeletal Infection Society (MSIS) has provided criteria for the diagnosis of PJI. The aim of our study was to analyze the utility of F18-fluorodeoxyglucose (FDG) positron emission tomography (PET) CT scan in the preoperative diagnosis of septic loosening in THA, based on the current MSIS definition of prosthetic joint infection. PATIENTS AND METHODS A total of 130 painful unilateral cemented THAs with a mean follow-up of 5.17 years (sd 1.12) were included in this prospective study. The mean patient age was 67.5 years (sd 4.85). Preoperative evaluation with inflammatory markers, aspiration, and an F18 FDG PET scan were performed. Diagnostic utility tests were also performed, based on the MSIS criteria for PJI and three samples positive on culture alone. RESULTS The mean erythrocyte sedimentation rate, C-reactive protein, and white cell count were 47.83 mm/hr, 25.21 mg/l, and 11.05 × 109/l, respectively. The sensitivity, specificity, accuracy, negative predictive value, and false-positive rate of FDG PET compared with MSIS criteria were 94.87%, 38.46 %, 56.38%, 94.59 %, and 60.21%, respectively. The false-positive rate of FDG PET compared with culture alone was 77.4%. CONCLUSION FDG PET has a definitive role in the preoperative evaluation of suspected PJI. This the first study to evaluate its utility based on MSIS criteria and compare it with microbiology results alone. However, FDG PET has a high false-positive rate. Therefore, we suggest that F18 FDG PET is useful in confirming the absence of infection, but if positive, may not be confirmatory of PJI. Cite this article: Bone Joint J 2019;101-B:910-914.
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Affiliation(s)
- M Kiran
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - T D Donnelly
- Trauma and Orthopaedics, Royal Liverpool University Hospital, Liverpool, UK
| | - C Armstrong
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - B Kapoor
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - G Kumar
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - V Peter
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
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Abstract
OBJECTIVE Quick identification of septic source is fundamental in patients with severe sepsis of unknown origin. The purpose of this case report was to assess the benefit and feasibility of an early PET-CT in critically ill patients with undiagnosed sepsis. DATA SOURCES Clinical observations of two patients. STUDY SELECTION Case reports. DATA EXTRACTION Data extracted from medical records, after patient's consent. Illustrations were collected from the imaging software. DATA SYNTHESIS We admitted two critically ill patients for suspected sepsis and altered mental state. As all bacteriological samples were initially sterile, diagnostic workups in both patients led us to suspect underlying malignant hemopathy. In fact, the lumbar puncture of the first patient revealed a large B-cell lymphoma, and an acquired thrombotic thrombocytopenic purpura was suspected in the second patient. However, PET-CTs performed in both patients displayed infra-clinical underlying infectious foci. Within 48 hours, both patients developed a clearly identified sepsis linked to the described focus, and favorable outcome thanks to the precious information delivered by the PET-CT. CONCLUSIONS PET-CT precisely detected the deep foci of infection about 48 hours prior to the diagnosis of sepsis. The cases reports suggested the use of this image technique in ICU for patients with sepsis of unknown origin.
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Sconfienza LM, Signore A, Cassar-Pullicino V, Cataldo MA, Gheysens O, Borens O, Trampuz A, Wörtler K, Petrosillo N, Winkler H, Vanhoenacker FMHM, Jutte PC, Glaudemans AWJM. Diagnosis of peripheral bone and prosthetic joint infections: overview on the consensus documents by the EANM, EBJIS, and ESR (with ESCMID endorsement). Eur Radiol 2019; 29:6425-6438. [PMID: 31250170 DOI: 10.1007/s00330-019-06326-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 05/27/2019] [Accepted: 06/12/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Peripheral bone infection (PBI) and prosthetic joint infection (PJI) are two different infectious conditions of the musculoskeletal system. They have in common to be quite challenging to be diagnosed and no clear diagnostic flowchart has been established. Thus, a conjoined initiative on these two topics has been initiated by the European Society of Radiology (ESR), the European Association of Nuclear Medicine (EANM), the European Bone and Joint Infection Society (EBJIS), and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID). The purpose of this work is to provide an overview on the two consensus documents on PBI and PJI that originated by the conjoined work of the ESR, EANM, and EBJIS (with ESCMID endorsement). METHODS AND RESULTS After literature search, a list of 18 statements for PBI and 25 statements for PJI were drafted in consensus on the most debated diagnostic challenges on these two topics, with emphasis on imaging. CONCLUSIONS Overall, white blood cell scintigraphy and magnetic resonance imaging have individually demonstrated the highest diagnostic performance over other imaging modalities for the diagnosis of PBI and PJI. However, the choice of which advanced diagnostic modality to use first depends on several factors, such as the benefit for the patient, local experience of imaging specialists, costs, and availability. Since robust, comparative studies among most tests do not exist, the proposed flowcharts are based not only on existing literature but also on the opinion of multiple experts involved on these topics. KEY POINTS • For peripheral bone infection and prosthetic joint infection, white blood cell and magnetic resonance imaging have individually demonstrated the highest diagnostic performance over other imaging modalities. • Two evidence- and expert-based diagnostic flowcharts involving variable combination of laboratory tests, biopsy methods, and radiological and nuclear medicine imaging modalities are proposed by a multi-society expert panel. • Clinical application of these flowcharts depends on several factors, such as the benefit for the patient, local experience, costs, and availability.
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Affiliation(s)
- Luca Maria Sconfienza
- IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161, Milan, Italy. .,Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy.
| | - Alberto Signore
- Nuclear Medicine Unit, Faculty of Medicine and Psychology, Department of Medical-Surgical Sciences and Translational Medicine, "Sapienza" University, Rome, Italy
| | - Victor Cassar-Pullicino
- Department of Diagnostic Imaging, The Robert Jones and Agnes Hunt Orthopaedic and District Hospital, Oswestry, Shropshire, UK
| | - Maria Adriana Cataldo
- Infectious Disease Unit, National Institute for Infectious Diseases "L. Spallanzani", IRCCS, Rome, Italy
| | - Olivier Gheysens
- Department of Nuclear Medicine and Molecular Imaging, University Hospitals Leuven, Leuven, Belgium
| | - Olivier Borens
- Division of Orthopaedic Surgery and Traumatology, Septic surgical unit, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Andrej Trampuz
- Center for Musculoskeletal Surgery (CMSC), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Klaus Wörtler
- Department of Diagnostic and Interventional Radiology, Technische Universität München, Munich, Germany
| | - Nicola Petrosillo
- Infectious Disease Unit, National Institute for Infectious Diseases "L. Spallanzani", IRCCS, Rome, Italy
| | - Heinz Winkler
- Osteitis-Centre, Privatklinik Döbling, Vienna, Austria
| | - Filip M H M Vanhoenacker
- Department of Radiology, Antwerp University Hospital and Antwerp University, Antwerp, Belgium.,AZ Sint-Maarten, Belgium, Mechelen, Belgium.,University of Ghent, Ghent, Belgium
| | - Paul C Jutte
- Department of Orthopaedic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Andor W J M Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Consensus document for the diagnosis of prosthetic joint infections: a joint paper by the EANM, EBJIS, and ESR (with ESCMID endorsement). Eur J Nucl Med Mol Imaging 2019; 46:971-988. [PMID: 30683987 PMCID: PMC6450843 DOI: 10.1007/s00259-019-4263-9] [Citation(s) in RCA: 107] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 01/02/2019] [Indexed: 12/13/2022]
Abstract
Background For the diagnosis of prosthetic joint infection, real evidence-based guidelines to aid clinicians in choosing the most accurate diagnostic strategy are lacking. Aim and Methods To address this need, we performed a multidisciplinary systematic review of relevant nuclear medicine, radiological, orthopaedic, infectious, and microbiological literature to define the diagnostic accuracy of each diagnostic technique and to address and provide evidence-based answers on uniform statements for each topic that was found to be important to develop a commonly agreed upon diagnostic flowchart. Results and Conclusion The approach used to prepare this set of multidisciplinary guidelines was to define statements of interest and follow the procedure indicated by the Oxford Centre for Evidence-based Medicine (OCEBM). Electronic supplementary material The online version of this article (10.1007/s00259-019-4263-9) contains supplementary material, which is available to authorized users.
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Pawaskar A, Basu S, Jahangiri P, Alavi A. In Vivo Molecular Imaging of Musculoskeletal Inflammation and Infection. PET Clin 2018; 14:43-59. [PMID: 30420221 DOI: 10.1016/j.cpet.2018.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In vivo molecular imaging detects biologic processes at molecular level and provides diagnostic information at an earlier time point during disease onset or repair. It offers definite advantage over anatomic imaging in terms of improved sensitivity and ability to quantify. Radionuclide molecular imaging has been widely used in clinical practice. This article discusses the role of radionuclide imaging in various infective and inflammatory diseases affecting musculoskeletal system with a focus on PET. It appears that, as more data become available, combined PET/MR imaging could emerge as a front runner in the imaging of musculoskeletal infection and inflammation.
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Affiliation(s)
- Alok Pawaskar
- Oncolife Cancer Centre, Satara, Maharashtra 415519, India; Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Centre Annexe, Parel, Mumbai, Maharashtra 400012, India
| | - Sandip Basu
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Centre Annexe, Parel, Mumbai, Maharashtra 400012, India; Homi Bhabha National Institute, Mumbai, Maharashtra, India.
| | - Pegah Jahangiri
- Division of Nuclear Medicine, Hospital of University of Pennsylvania, Philadelphia, PA, USA
| | - Abass Alavi
- Division of Nuclear Medicine, Hospital of University of Pennsylvania, Philadelphia, PA, USA
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18
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19
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Fluorodeoxyglucose positron emission tomography imaging for diagnosing periprosthetic hip infection: the importance of diagnostic criteria. INTERNATIONAL ORTHOPAEDICS 2018; 42:2025-2034. [DOI: 10.1007/s00264-018-3931-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 04/05/2018] [Indexed: 10/17/2022]
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20
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Palestro CJ, Love C. Role of Nuclear Medicine for Diagnosing Infection of Recently Implanted Lower Extremity Arthroplasties. Semin Nucl Med 2017; 47:630-638. [PMID: 28969761 DOI: 10.1053/j.semnuclmed.2017.07.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Infection is an infrequent complication of lower extremity prosthetic joint surgery. Approximately one-third develop within 3 months (early), another third within 1 year (delayed), and the remainder more than 1 year (late) after surgery. Diagnosing prosthetic joint infection, especially in the early postoperative period during the first year, is challenging. Pain is almost always present. The presence of fever is variable, ranging from less than 5% to more than 40% of patients. Leukocytosis is a poor predictor of infection. After primary uncomplicated arthroplasty, the C-reactive protein remains elevated for up to 3 weeks. The erythrocyte sedimentation rate can remain elevated for up to 1 year. Although joint aspiration with culture, the definitive preoperative diagnostic procedure, is specific, its sensitivity is variable. Plain radiographs lack sensitivity and specificity. Radionuclide studies are useful for evaluating painful joint replacements, but data on their utility during the early postoperative period are limited. During the first year after arthroplasty insertion, the bone scan can exclude infection. It is a good "rule-out" test, but it is not reliable for "ruling in" infection. Gallium-67 accumulates in normally healing surgical incisions and in aseptic inflammation. With an accuracy of 60%-80% for diagnosing prosthetic joint infection, there is little role for this radiopharmaceutical for evaluating prosthetic joints, regardless of age. Although data about diagnosing prosthetic joint infection with 18F-FDG in the early postoperative period are lacking, uptake of this radiopharmaceutical in a variety of postoperative settings for variable time periods is well known. Furthermore, its utility for diagnosing prosthetic joint infection in general, after nearly 2 decades of investigation, remains to be established. Indium-111-labeled leukocytes do not accumulate in normally healing surgical wounds, and in combination with marrow imaging, the test is about 90% accurate for diagnosing prosthetic joint infection. Preliminary data indicate a comparable accuracy in the early postoperative period.
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22
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Verberne SJ, Raijmakers PG, Temmerman OPP. The Accuracy of Imaging Techniques in the Assessment of Periprosthetic Hip Infection: A Systematic Review and Meta-Analysis. J Bone Joint Surg Am 2016; 98:1638-1645. [PMID: 27707850 DOI: 10.2106/jbjs.15.00898] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Various imaging techniques are used for excluding or confirming periprosthetic hip infection, but there is no consensus regarding the most accurate technique. The objective of this study was to determine the accuracy of current imaging modalities in diagnosing periprosthetic hip infection. METHODS A systematic review and meta-analysis of the literature was conducted with a comprehensive search of MEDLINE and Embase to identify clinical studies in which periprosthetic hip infection was investigated with different imaging modalities. The sensitivity and specificity of each imaging technique were determined and compared with the results of microbiological and histological analysis, intraoperative findings, and clinical follow-up of >6 months. RESULTS A total of 31 studies, published between 1988 and 2014, were included for meta-analysis, representing 1,753 hip prostheses. Quality assessment of the included studies identified low concerns with regard to external validity but more concerns with regard to internal validity including risk of bias (>50% of studies had insufficient information). No meta-analysis was performed for radiography, ultrasonography, computed tomography, and magnetic resonance imaging because of insufficient available clinical data. The pooled sensitivity and specificity were 88% (95% confidence interval [CI], 81% to 94%) and 92% (95% CI, 88% to 96%), respectively, for leukocyte scintigraphy; 86% (95% CI, 80% to 90%) and 93% (95% CI, 90% to 95%) for fluorodeoxyglucose positron emission tomography (FDG PET); 69% (95% CI, 58% to 79%) and 96% (95% CI, 93% to 98%) for combined leukocyte and bone marrow scintigraphy; 84% (95% CI, 70% to 93%) and 75% (95% CI, 66% to 82%) for antigranulocyte scintigraphy; and 80% (95% CI, 72% to 86%) and 69% (95% CI, 64% to 73%) for bone scintigraphy. CONCLUSIONS Of the currently used imaging techniques, leukocyte scintigraphy has satisfactory accuracy in confirming or excluding periprosthetic hip infection. Although not significantly different, combined leukocyte and bone marrow scintigraphy was the most specific imaging technique. FDG PET has an appropriate accuracy in confirming or excluding periprosthetic hip infection, but may not yet be the preferred imaging modality because of limited availability and relatively higher cost. LEVEL OF EVIDENCE Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- S J Verberne
- Department of Orthopaedics and Centre for Orthopaedic Research Alkmaar (CORAL), Medical Centre Alkmaar, Alkmaar, the Netherlands
| | - P G Raijmakers
- Department of Radiology & Nuclear Medicine, VU University Medical Centre, Amsterdam, the Netherlands
| | - O P P Temmerman
- Department of Orthopaedics and Centre for Orthopaedic Research Alkmaar (CORAL), Medical Centre Alkmaar, Alkmaar, the Netherlands
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Palestro CJ. Radionuclide Imaging of Musculoskeletal Infection: A Review. J Nucl Med 2016; 57:1406-12. [PMID: 27390160 DOI: 10.2967/jnumed.115.157297] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 06/29/2016] [Indexed: 12/12/2022] Open
Abstract
There are numerous imaging tests for diagnosing musculoskeletal infection. Radiographs are routinely performed, because even when not diagnostic, they provide an anatomic overview of the region of interest that could influence subsequent procedure selection and interpretation. MRI is sensitive and provides superb anatomic detail. Bone scintigraphy accurately diagnoses osteomyelitis in bones not affected by underlying conditions. (67)Ga is used primarily for spondylodiskitis. Although in vitro labeled leukocyte imaging is the radionuclide test of choice for complicating osteomyelitis such as diabetic pedal osteomyelitis and prosthetic joint infection, it is not useful for spondylodiskitis. Antigranulocyte antibodies and antibody fragments have limitations and are not widely available. (111)In-biotin is useful for spondylodiskitis. Radiolabeled synthetic fragments of the antimicrobial peptide ubiquicidin are promising infection-specific agents. (18)F-FDG is the radiopharmaceutical of choice for spondylodiskitis. Its role in diabetic pedal osteomyelitis and prosthetic joint infection is not established. Preliminary data suggest (68)Ga may be useful in musculoskeletal infection. (124)I-fialuridine initially showed promise as an infection-specific radiopharmaceutical, but subsequent investigations were disappointing. The development of PET/CT and SPECT/CT imaging systems, which combine anatomic and functional imaging, has revolutionized diagnostic imaging. These hybrid systems are redefining the diagnostic workup of patients with suspected or known infection and inflammation by improving diagnostic accuracy and influencing patient management.
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24
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Abstract
There is currently no consensus on the optimal management of the infected total hip arthroplasty. Multiple management techniques have been described in contemporary literature.This paper focuses on 2-stage revision for the infected total hip arthroplasty. We discuss the rationale and examine the current evidence for the use of this technique.
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25
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Love C, Palestro CJ. Nuclear medicine imaging of bone infections. Clin Radiol 2016; 71:632-46. [PMID: 26897336 DOI: 10.1016/j.crad.2016.01.003] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 12/24/2015] [Accepted: 01/04/2016] [Indexed: 02/08/2023]
Abstract
Osteomyelitis is a broad group of infectious diseases that involve the bone and/or bone marrow. It can arise haematogenously, via extension from a contiguous infection, or by direct inoculation during surgery or trauma. The diagnosis is not always obvious and imaging tests are frequently performed as part of the diagnostic work-up. Commonly performed radionuclide tests include technetium-99m ((99m)Tc)-diphosphonate bone scintigraphy (bone), and gallium-67 ((67)Ga) and in vitro labelled leukocyte (white blood cell; WBC) imaging. Although they are useful, each of these tests has limitations. Bone scintigraphy is sensitive but not specific, especially when underlying osseous abnormalities are present. (67)Ga accumulates in tumour, trauma, and in aseptic inflammation; furthermore, there is typically an interval of 1-3 days between radiopharmaceutical injection of and imaging. Currently, this agent is used primarily for spinal infections. Except for the spine, WBC imaging is the nuclear medicine test of choice for diagnosing complicating osteomyelitis. The in vitro leukocyte labelling process requires skilled personnel, is laborious, and is not always available. Complementary marrow imaging is usually required to maximise accuracy. Not surprisingly, alternative radiopharmaceuticals are continuously being investigated. Radiolabelled anti-granulocyte antibodies and antibody fragments, investigated as in vivo leukocyte labelling agents, have their own limitations and are not widely available. (111)In-biotin is useful for diagnosing spinal infections. Radiolabelled synthetic fragments of ubiquicidin, a naturally occurring human antimicrobial peptide that targets bacteria, have shown promise as infection specific radiopharmaceuticals. 2-[(18)F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography (PET) with or without computed tomography (CT) is very useful in musculoskeletal infection. Sensitivities of more than 95% and specificities ranging from 75-99% have been reported in acute and subacute bone and soft-tissue infection. FDG is the radionuclide test of choice for spinal infection. It is sensitive, has a high negative predictive value, and can differentiate degenerative from infectious vertebral body end-plate abnormalities. Data on the accuracy of FDG for diagnosing diabetic pedal osteomyelitis and prosthetic joint infection are inconclusive and its role for these indications remains to be determined. Other PET radiopharmaceuticals that are under investigation as infection imaging agents include gallium-68 citrate ((68)Ga) and iodine-124 fialuridine ((124)I -FIAU).
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Affiliation(s)
- C Love
- Division of Nuclear Medicine, PET/CT Center, Montefiore Medical Center, 1695A Eastchester Road, Bronx, NY 11755, USA.
| | - C J Palestro
- Division of Nuclear Medicine & Molecular Imaging, Northwell Health, Manhasset & New Hyde Park, NY, USA
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26
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Chatziioannou S, Papamichos O, Gamaletsou MN, Georgakopoulos A, Kostomitsopoulos NG, Tseleni-Balafouta S, Papaparaskevas J, Walsh TJ, Pneumaticos SG, Sipsas NV. 18-Fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography scan for monitoring the therapeutic response in experimental Staphylococcus aureus foreign-body osteomyelitis. J Orthop Surg Res 2015; 10:132. [PMID: 26306506 PMCID: PMC4550045 DOI: 10.1186/s13018-015-0274-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 08/08/2015] [Indexed: 02/05/2023] Open
Abstract
Background 18-Fluoro-2-deoxy-d-glucose positron emission tomography combined with computed tomography (18F-FDG PET/CT) scan is useful for diagnosis of osteoarticular infections. Whether 18F-FDG PET/CT scanning may be used for therapeutic monitoring is not clear. The objective of this study was to develop 18F-FDG PET/CT scanning for monitoring therapeutic response to antimicrobials in experimental Staphylococcus aureus osteomyelitis. Methods A total of 22 rabbits were studied. In 20 animals, the right tibia was inoculated intraoperatively with S. aureus. Two control animals were inoculated with normal saline. A needle was placed in the tibia as a foreign body. Infection was allowed to develop for 21 days when 18F-FDG PET/CT was performed, the needle was removed, and bone specimens were cultured to confirm infection. Antimicrobial therapy with daptomycin was initiated in all successfully infected animals for 1, 3, or 6 weeks. Following completion of treatment, a second 18F-FDG PET/CT was performed, animals were euthanized, and infected tibias were harvested for quantitative cultures and histology. A positive scan was defined as 18F-FDG signal activity greater in the infected tibia than that of the contralateral non-infected control tibia. Therapeutic response was measured by the change of 18F-FDG signal activity in the infected tibia. Results All successfully infected animals (n = 14), with microbiologically and/or histologically confirmed osteomyelitis, had positive 18F-FDG PET/CT scans, while the two control animals had negative scans despite the presence of the foreign body [mean maximum standardized uptake value (SUVmax) (±SD) values 2.96 (±0.80) vs. 1 (±1.10), respectively, P = 0.04]. In the 14 successfully infected animals, the mean SUVmax was significantly higher in the infected compared to the uninfected tibia (P < 0.0001). A SUVmax of 1.4, when used as a cutoff for infection, yielded a diagnostic accuracy of 93 %. At the end of treatment, successfully treated animals and saline controls had a negative 18F-FDG PET/CT scan (n = 4), while animals with persistent infection despite treatment (n = 12) had a positive 18F-FDG PET/CT scan (SUVmax 1.0–3.0) (p < 0.001). SUVmax values were significantly reduced after 42 days of treatment from 3.15 ± 0.5 (day 7) to 1.71 ± 0.37 (day 42) (p = 0.05). Conclusions 18F-FDG PET/CT scan is a sensitive and specific tool in therapeutic monitoring of experimental foreign-body osteomyelitis.
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Affiliation(s)
- Sofia Chatziioannou
- Second Department of Radiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece. .,PET/CT Section, Foundation for Biomedical Research of the Academy of Athens, Athens, Greece.
| | - Odysseas Papamichos
- Third Department of Orthopedics, Medical School, National and Kapodistrian University of Athens, Athens, Greece.
| | - Maria N Gamaletsou
- Department of Pathophysiology, Medical School, National and Kapodistrian University of Athens, Mikras Asias 75, Athens, 115 27, Greece.
| | | | - Nikolaos G Kostomitsopoulos
- Center for Experimental Surgery, Foundation for Biomedical Research of the Academy of Athens, Athens, Greece.
| | - Sofia Tseleni-Balafouta
- Department of Pathology, Medical School, National and Kapodistrian University of Athens, Athens, Greece.
| | - Joseph Papaparaskevas
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece.
| | - Thomas J Walsh
- Departments of Medicine, Pediatrics, and Microbiology & Immunology, Weill Cornell Medical Center of Cornell University, New York, NY, USA.
| | - Spiros G Pneumaticos
- Third Department of Orthopedics, Medical School, National and Kapodistrian University of Athens, Athens, Greece.
| | - Nikolaos V Sipsas
- Department of Pathophysiology, Medical School, National and Kapodistrian University of Athens, Mikras Asias 75, Athens, 115 27, Greece.
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Abstract
Radionuclide procedures frequently are performed as part of the diagnostic workup of osteomyelitis. Bone scintigraphy accurately diagnoses osteomyelitis in bones not affected by underlying conditions. Degenerative joint disease, fracture, and orthopedic hardware decrease the specificity of the bone scan, making it less useful in these situations. Gallium-67 scintigraphy was often used as an adjunct to bone scintigraphy for diagnosing osteomyelitis. However, now it is used primarily for spinal infections when (18)F-FDG imaging cannot be performed. Except for the spine, in vitro-labeled leukocyte imaging is the nuclear medicine test of choice for diagnosing complicating osteomyelitis. Leukocytes accumulate in bone marrow as well as in infection. Performing complementary bone marrow imaging with (99m)Tc-sulfur colloid facilitates the differentiation between osteomyelitis and normal marrow and improves test overall accuracy. Antigranulocyte antibodies and antibody fragments, such as (99m)Tc-besilesomab and (99m)Tc-sulesomab, were developed to eliminate the disadvantages associated with in vitro-labeled leukocytes. These agents, however, have their own shortcomings and are not widely available. As biotin is used as a growth factor by certain bacteria, (111)In-biotin is useful to diagnose spinal infections. Radiolabeled synthetic fragments of ubiquicidin, a naturally occurring human antimicrobial peptide that targets bacteria, can differentiate infection from sterile inflammation and may be useful to monitor response to treatment. (18)F-FDG is extremely useful in the diagnostic workup of osteomyelitis. Sensitivity in excess of 95% and specificity ranging from 75%-99% have been reported. (18)F-FDG is the radionuclide test of choice for spinal infection. The test is sensitive, with a high negative predictive value, and reliably differentiates degenerative from infectious vertebral body end-plate abnormalities. Data on the accuracy of (18)F-FDG for diagnosing diabetic pedal osteomyelitis are contradictory, and its role for this indication remains to be determined. Initial investigations suggested that (18)F-FDG accurately diagnoses prosthetic joint infection; more recent data indicate that it cannot differentiate infection from other causes of prosthetic failure. Preliminary data on the PET agents gallium-68 and iodine-124 fialuridine indicate that these agents may have a role in diagnosing osteomyelitis.
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Affiliation(s)
- Christopher J Palestro
- Department of Radiology Hofstra, NorthShore-LIJ School of Medicine, Hempstead, NY; Division of Nuclear Medicine and Molecular Imaging, North Shore Long Island Jewish Health System, Manhasset & New Hyde Park, NY.
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Gelfand MJ, Sharp SE. [F-18]2-fluoro-2-deoxyglucose (FDG) positron emission tomography after limb salvage surgery: post-surgical appearance, attenuation correction and local complications. Pediatr Radiol 2015; 45:1182-8. [PMID: 25721581 DOI: 10.1007/s00247-015-3290-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 10/12/2014] [Accepted: 01/21/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Metal endoprostheses and internal fixation devices cause significant artifacts on CT after limb salvage surgery; positron emission tomography (PET) images should be evaluated for artifacts. OBJECTIVE (1) To describe [F-18]2-fluoro-2-deoxyglucose (FDG) PET uptake patterns after limb salvage surgery. (2) To determine whether metal endoprostheses and fixation hardware cause significant artifacts on CT attenuation-corrected PET that interfere with diagnostic use of PET/CT after limb salvage surgery. MATERIALS AND METHODS We reviewed 92 studies from 18 patients ages 5-21 years. Diagnoses were osteogenic sarcoma in 14, Ewing sarcoma in 3, and malignant peripheral nerve sheath tumor originating in bone in 1. Nine patients had distal femur/knee endoprostheses, five had lower-extremity bone allografts secured by large metal plates and four had upper-extremity limb salvage procedures. Maximum standardized uptake value was calculated at lower-extremity soft-tissue-endoprosthesis interfaces. In 15 patients with PET/CT imaging, the first PET/CT scan after limb salvage surgery was reviewed for metal artifacts on CT images and for artifacts at locations on PET corresponding to the CT metal artifacts. RESULTS Increased FDG uptake was consistently present at soft-tissue interfaces with endoprostheses, allografts and internal fixation devices, with little or no FDG uptake at cemented endoprosthesis-bone interfaces. Maximum standardized uptake value at margins of femur/knee endoprostheses ranged from 1.4 to 5.7. In four patients with distal femur/knee endoprostheses, minimal artifact was noted on attenuation-corrected PET images, but image interpretation was not affected. In the other 11 patients who had CT attenuation correction, we detected no artifacts caused by the attenuation correction. CONCLUSION CT attenuation correction did not cause artifacts that affected interpretation of attenuation-corrected PET images.
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Affiliation(s)
- Michael J Gelfand
- Department of Radiology, Nuclear Medicine Division, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229-3026, USA,
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Diaz-Ledezma C, Lamberton C, Lichstein P, Parvizi J. Diagnosis of Periprosthetic Joint Infection: The Role of Nuclear Medicine May Be Overestimated. J Arthroplasty 2015; 30:1044-9. [PMID: 25686785 DOI: 10.1016/j.arth.2015.01.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 01/05/2015] [Accepted: 01/12/2015] [Indexed: 02/07/2023] Open
Abstract
Although the International Consensus Meeting on Periprosthetic Joint Infection's definition of periprosthetic joint infection (PJI) does not include nuclear imaging as part of the diagnostic criteria, many contemporary nuclear imaging studies are reporting exceptional results in PJI diagnosis. We conducted a systematic review of studies published from 2004 to 2012 reporting the accuracy of nuclear imaging for diagnosis of PJI, utilizing a specially designed tool (QUADAS-2) for critical appraisal and investigation of bias. Our results revealed high risk of bias as well as high levels of concern regarding the clinical applicability of these tests in a majority of the studies. On the basis of our findings, we recommend that the use of nuclear imaging for diagnosis of PJI be limited to a few select cases.
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Affiliation(s)
- Claudio Diaz-Ledezma
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Courtney Lamberton
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Paul Lichstein
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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The use of nuclear imaging for the diagnosis of periprosthetic infection after knee and hip arthroplasties. Nucl Med Commun 2015; 36:305-11. [DOI: 10.1097/mnm.0000000000000266] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Bou Monsef J, Schraut N, Gonzalez M. Failed Total Knee Arthroplasty. JBJS Rev 2014; 2:01874474-201412000-00001. [PMID: 27490508 DOI: 10.2106/jbjs.rvw.n.00025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jad Bou Monsef
- Department of Orthopedic Surgery, University of Illinois at Chicago, 835 South Walcott Avenue, Room E270, Chicago, IL, 60612
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Lewis SS, Cox GM, Stout JE. Clinical utility of indium 111-labeled white blood cell scintigraphy for evaluation of suspected infection. Open Forum Infect Dis 2014; 1:ofu089. [PMID: 25734155 PMCID: PMC4281781 DOI: 10.1093/ofid/ofu089] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 09/02/2014] [Indexed: 01/18/2023] Open
Abstract
We assessed the clinical utility of indium 111–labeled white blood cell scans at our tertiary referral center from 2005 to 2011. Overall, scans meaningfully impacted clinical care <50% of the time. Scan utility was greater for suspected vascular graft infections or osteomyelitis. Background We sought to characterize the clinical utility of indium 111 (111In)–labeled white blood cell (WBC) scans by indication, to identify patient populations who might benefit most from this imaging modality. Methods Medical records for all patients who underwent 111In-labeled WBC scans at our tertiary referral center from 2005 to 2011 were reviewed. Scan indication, results, and final diagnosis were assessed independently by 2 infectious disease physicians. Reviewers also categorized the clinical utility of each scan as helpful vs not helpful with diagnosis and/or management according to prespecified criteria. Cases for which clinical utility could not be determined were excluded from the utility assessment. Results One hundred thirty-seven scans were included in this analysis; clinical utility could be determined in 132 (96%) cases. The annual number of scans decreased throughout the study period, from 26 in 2005 to 13 in 2011. Forty-one (30%) scans were positive, and 85 (62%) patients were ultimately determined to have an infection. Of the evaluable scans, 63 (48%) scans were deemed clinically useful. Clinical utility varied by scan indication: 111In-labeled WBC scans were more helpful for indications of osteomyelitis (35/50, 70% useful) or vascular access infection (10/15, 67% useful), and less helpful for evaluation of fever of unknown origin (12/35, 34% useful). Conclusions 111In-labeled WBC scans were useful for patient care less than half of the time at our center. Targeted ordering of these scans for indications in which they have greater utility, such as suspected osteomyelitis and vascular access infections, may optimize test utilization.
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Affiliation(s)
- Sarah S Lewis
- Division of Infectious Diseases , Duke University Medical Center , Durham, North Carolina
| | - Gary M Cox
- Division of Infectious Diseases , Duke University Medical Center , Durham, North Carolina
| | - Jason E Stout
- Division of Infectious Diseases , Duke University Medical Center , Durham, North Carolina
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Palestro CJ. Nuclear medicine and the failed joint replacement: Past, present, and future. World J Radiol 2014; 6:446-458. [PMID: 25071885 PMCID: PMC4109096 DOI: 10.4329/wjr.v6.i7.446] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 02/26/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
Soon after the introduction of the modern prosthetic joint, it was recognized that radionuclide imaging provides useful information about these devices. The bone scan was used extensively to identify causes of prosthetic joint failure. It became apparent, however, that although sensitive, regardless of how the images were analyzed or how it was performed, the test was not specific and could not distinguish among the causes of prosthetic failure. Advances in anatomic imaging, notably cross sectional modalities, have facilitated the diagnosis of many, if not most, causes of prosthetic failure, with the important exception of infection. This has led to a shift in the diagnostic paradigm, in which nuclear medicine investigations increasingly have focused on diagnosing infection. The recognition that bone scintigraphy could not reliably diagnose infection led to the development of combined studies, first bone/gallium and subsequently leukocyte/bone and leukocyte/marrow imaging. Labeled leukocyte imaging, combined with bone marrow imaging is the most accurate (about 90%) imaging test for diagnosing joint arthroplasty infection. Its value not withstanding, there are significant disadvantages to this test. In-vivo techniques for labeling leukocytes, using antigranulocyte antibodies have been explored, but have their own limitations and the results have been inconsistent. Fluorodeoxyglucose (FDG)-positron emission tomography (FDG-PET) has been extensively investigated for more than a decade but its role in diagnosing the infected prosthesis has yet to be established. Antimicrobial peptides bind to bacterial cell membranes and are infection specific. Data suggest that these agents may be useful for diagnosing prosthetic joint infection, but large scale studies have yet to be undertaken. Although for many years nuclear medicine has focused on diagnosing prosthetic joint infection, the advent of hybrid imaging with single-photon emission computed tomography(SPECT)/electronic computer X-ray tomography technique (CT) and the availability of fluorine-18 fluoride PET suggests that the diagnostic paradigm may be shifting again. By providing the anatomic information lacking in conventional radionuclide studies, there is renewed interest in bone scintigraphy, performed as a SPECT/CT procedure, for detecting joint instability, mechanical loosening and component malpositioning. Fluoride-PET may provide new insights into periprosthetic bone metabolism. The objective of this manuscript is to provide a comprehensive review of the evolution of nuclear medicine imaging of joint replacements.
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Revest M, Patrat-Delon S, Devillers A, Tattevin P, Michelet C. Contribution of 18fluoro-deoxyglucose PET/CT for the diagnosis of infectious diseases. Med Mal Infect 2014; 44:251-60. [DOI: 10.1016/j.medmal.2014.04.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 02/03/2014] [Accepted: 04/16/2014] [Indexed: 10/25/2022]
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Yilmaz S, Vatankulu B, Ekmekciogu O, Sager S, Halac M. FDG and FDG-labelled leucocyte PET/CT in the imaging of prosthetic joint infection: response to Lazzeri et al. Eur J Nucl Med Mol Imaging 2014; 41:1813-4. [PMID: 24802195 DOI: 10.1007/s00259-014-2778-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 03/28/2014] [Indexed: 10/25/2022]
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Milone MT, Kamath AF, Israelite CL. Converting between high- and low-sensitivity C-reactive protein in the assessment of periprosthetic joint infection. J Arthroplasty 2014; 29:685-9. [PMID: 24140275 DOI: 10.1016/j.arth.2013.09.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 09/09/2013] [Accepted: 09/16/2013] [Indexed: 02/01/2023] Open
Abstract
Although low-sensitivity CRP (Ls-CRP) is an important tool for evaluating infected orthopedic prostheses, no clinical studies have evaluated whether Hs-CRP is a suitable surrogate for Ls-CRP or other traditional infection biomarkers. The laboratory data of 98 arthroplasty patients with suspected prosthetic infection were reviewed. Hs-CRP was highly correlated with Ls-CRP (R = 0.93). ROC analysis generated 100% sensitivity and 97% specificity for both Hs-CRP and Ls-CRP at optimal cutoffs of 28.6 and 2.6 mg/dL, respectively. Both CRP tests were more accurate than serum erythrocyte sedimentation rate, neutrophil differential, and white blood cell count. Hs-CRP was no different from Ls-CRP after unit conversion, and regression analyses suggested conversion factors that approximated 10. Hs-CRP and Ls-CRP have equivalent utility in the diagnosis of infected joint arthroplasty.
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Affiliation(s)
- Michael T Milone
- Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Atul F Kamath
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester MN
| | - Craig L Israelite
- Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
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Chen W, Kim J, Molchanova-Cook OP, Dilsizian V. The Potential of FDG PET/CT for Early Diagnosis of Cardiac Device and Prosthetic Valve Infection Before Morphologic Damages Ensue. Curr Cardiol Rep 2014; 16:459. [DOI: 10.1007/s11886-013-0459-y] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Cobo J, Del Pozo JL. Prosthetic joint infection: diagnosis and management. Expert Rev Anti Infect Ther 2014; 9:787-802. [DOI: 10.1586/eri.11.95] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Periprosthetic joint infections: clinical and bench research. ScientificWorldJournal 2013; 2013:549091. [PMID: 24288493 PMCID: PMC3826319 DOI: 10.1155/2013/549091] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 08/01/2013] [Indexed: 01/27/2023] Open
Abstract
Prosthetic joint infection is a devastating complication with high morbidity and substantial cost. The incidence is low but probably underestimated. Despite a significant basic and clinical research in this field, many questions concerning the definition of prosthetic infection as well the diagnosis and the management of these infections remained unanswered. We review the current literature about the new diagnostic methods, the management and the prevention of prosthetic joint infections.
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Jamar F, Buscombe J, Chiti A, Christian PE, Delbeke D, Donohoe KJ, Israel O, Martin-Comin J, Signore A. EANM/SNMMI guideline for 18F-FDG use in inflammation and infection. J Nucl Med 2013; 54:647-58. [PMID: 23359660 DOI: 10.2967/jnumed.112.112524] [Citation(s) in RCA: 379] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Francois Jamar
- Department of Nuclear Medicine, Université Catholique de Louvain, Brussels, Belgium
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FDG PET imaging for diagnosing prosthetic joint infection: discussing the facts, rectifying the unsupported claims and call for evidence-based and scientific approach. Eur J Nucl Med Mol Imaging 2013; 40:464-6. [DOI: 10.1007/s00259-012-2319-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Accepted: 12/10/2012] [Indexed: 11/27/2022]
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Production and separation of 111In: an important radionuclide in life sciences: a mini review. J Radioanal Nucl Chem 2012. [DOI: 10.1007/s10967-012-2344-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Saboury B, Ziai P, Parsons M, Zhuang H, Basu S, Alavi A. Promising Roles of PET in Management of Arthroplasty-Associated Infection. PET Clin 2012; 7:139-50. [PMID: 27157232 DOI: 10.1016/j.cpet.2012.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A number of diagnostic tests is often necessary to differentiate aseptic loosening from periprosthetic infection in most clinical settings. The accuracy of [(18)F]Fluorodeoxyglucose examined with positron emission tomography imaging (FDG PET) in diagnosing periprosthetic infection has been determined by a number of investigations. In general, Images are considered positive for infection if they demonstrate increased FDG activity at the bone-prosthesis interface of the prostheses. Based on the large number of reports in the literature the sensitivity and specificity for FDG PET are about 85-90%. The overall accuracy of this non-invasive imaging modality is superior to the other existing imaging techniques. Therefore, FDG PET appears a very promising and accurate diagnosing tool for distinguishing septic from aseptic painful hip prostheses.
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Affiliation(s)
- Babak Saboury
- Department of Radiology, School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Pouya Ziai
- Department of Radiology, School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Molly Parsons
- Department of Radiology, School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Hongming Zhuang
- Division of Nuclear Medicine, Department of Radiology, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Sandip Basu
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Hospital Annexe, Parel, Bombay 400012, India
| | - Abass Alavi
- Department of Radiology, School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
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Gemmel F, Van den Wyngaert H, Love C, Welling MM, Gemmel P, Palestro CJ. Prosthetic joint infections: radionuclide state-of-the-art imaging. Eur J Nucl Med Mol Imaging 2012; 39:892-909. [PMID: 22361912 DOI: 10.1007/s00259-012-2062-7] [Citation(s) in RCA: 139] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Accepted: 01/02/2012] [Indexed: 12/27/2022]
Abstract
Prosthetic joint replacement surgery is performed with increasing frequency. Overall the incidence of prosthetic joint infection (PJI) and subsequently prosthesis revision failure is estimated to be between 1 and 3%. Differentiating infection from aseptic mechanical loosening, which is the most common cause of prosthetic failure, is especially important because of different types of therapeutic management. Despite a thorough patient history, physical examination, multiple diagnostic tests and complex algorithms, differentiating PJI from aseptic loosening remains challenging. Among imaging modalities, radiographs are neither sensitive nor specific and cross-sectional imaging techniques, such as computed tomography and magnetic resonance imaging, are limited by hardware-induced artefacts. Radionuclide imaging reflects functional rather than anatomical changes and is not hampered by the presence of a metallic joint prosthesis. As a result scintigraphy is currently the modality of choice in the investigation of suspected PJI. Unfortunately, there is no true consensus about the gold standard technique since there are several drawbacks and limitations inherent to each modality. Bone scintigraphy (BS) is sensitive for identifying the failed joint replacement, but cannot differentiate between infection and aseptic loosening. Combined bone/gallium scintigraphy (BS/GS) offers modest improvement over BS alone for diagnosing PJI. However, due to a number of drawbacks, BS/GS has generally been superseded by other techniques but it still may have a role in neutropenic patients. Radiolabelled leucocyte scintigraphy remains the gold standard technique for diagnosing neutrophil-mediated processes. It seems to be that combined in vitro labelled leucocyte/bone marrow scintigraphy (LS/BMS), with an accuracy of about 90%, is currently the imaging modality of choice for diagnosing PJI. There are, however, significant limitations using in vitro labelled leucocytes and considerable effort has been devoted to developing alternative radiotracers, such as radiolabelled HIGs, liposomes, antigranulocyte antibodies and fragments, as well as more investigational tracers such as radiolabelled antibiotics, antimicrobial peptides, bacteriophages and thymidine kinase. On the other hand, positron emission tomography (PET) is still growing in the field of PJI imaging with radiotracers such as (18)F-fluorodeoxyglucose (FDG), (18)F-FDG white blood cells and (18)F-fluoride. But unfortunately this superb tomographic technique will only receive full acceptance when specific PET uptake patterns can be successfully developed. The emergence of hybrid modality imaging using integrated single photon emission computed tomography (SPECT) and PET with computed tomography (SPECT/CT and PET/CT) may also have a contributing role for more accurate assessment of joint replacement complications, especially combined with new radiotracers such as (68)Ga and (64)Cu. Finally, in searching for infection-specific tracers, currently there is no such diagnostic agent available.
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Affiliation(s)
- Filip Gemmel
- Department of Nuclear Medicine, AZ Alma Campus Sijsele, Gentse Steenweg 132, 8340 Sijsele-Damme, Belgium.
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Choe H, Inaba Y, Kobayashi N, Ike H, Aoki C, Shizukuishi K, Iwamoto N, Yukizawa Y, Ishida T, Inoue T, Saito T. Use of 18F-fluoride PET to determine the appropriate tissue sampling region for improved sensitivity of tissue examinations in cases of suspected periprosthetic infection after total hip arthroplasty. Acta Orthop 2011; 82:427-32. [PMID: 21671714 PMCID: PMC3237032 DOI: 10.3109/17453674.2011.594232] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE The accurate diagnosis of periprosthetic infection requires assessment of intraoperative tissues. These must be sampled from the appropriate sites. We used (18)F-fluoride positron emission tomography (PET) to identify sites of inflammation in order to improve the sensitivity of histopathology, microbiological culture, and real-time PCR in total hip arthroplasty (THA) patients. PATIENTS AND METHODS 23 THA patients (23 hips) scheduled for revision surgery (the revision group) and 17 uninfected THA patients (23 hips; control group) were enrolled. Uptake was classified into major, minor, and no uptake. To evaluate the association between the (18)F-fluoride uptake and intraoperative tissue results in the revision group, we calculated their sensitivity on each of the major, minor, and no-uptake sides. RESULTS 17 revision patients showed major uptake and all were diagnosed as having septic loosening from intraoperative tissue results. Minor uptake was observed in the other 6 revision patients and all were diagnosed as having aseptic loosening. Apart from 3 cases that showed minor uptake regions, control subjects showed no uptake. In the revision group, the sensitivities of histopathology, microbiological culture, real-time PCR separately and also in combination were 0.78, 0.58, 0.96, and 0.96, respectively, on the major (18)F-fluoride uptake sides, 0.0, 0.0, 0.1, and 0.1 on the minor-uptake sides, and 0, 0, 0.18, and 0.18 on the no-uptake sides. INTERPRETATION Our findings suggest that preoperative assessment of major uptake of (18)F-fluoride markedly improves the accuracy of tissue sampling, and thus the sensitivity of subsequent tissue examinations. More definitive diagnosis of periprosthetic infection is therefore possible.
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Affiliation(s)
| | | | | | | | | | - Kazuya Shizukuishi
- Department of Radiology, School of Medicine, Yokohama City University, Yokohama, Japan
| | | | | | | | - Tomio Inoue
- Department of Radiology, School of Medicine, Yokohama City University, Yokohama, Japan
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van der Bruggen W, Bleeker-Rovers CP, Boerman OC, Gotthardt M, Oyen WJG. PET and SPECT in osteomyelitis and prosthetic bone and joint infections: a systematic review. Semin Nucl Med 2010; 40:3-15. [PMID: 19958846 DOI: 10.1053/j.semnuclmed.2009.08.005] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To review the literature on diagnostic accuracy and clinical value of single-photon emission computed tomography (SPECT) and positron emission tomography (PET) for imaging of bone and joint infections. METHODS The PubMed/MEDLINE and Embase (OvidSP) literature databases were systematically searched for publications on SPECT and PET on osteomyelitis and prosthetic bone and joint infections using specific guidelines with MeSH-terms, truncations, and completion using cross-references. RESULTS In 44 original articles (15 for SPECT and 29 for (18)F-fluorodeoxyglucose [FDG]-PET) on osteomyelitis and prosthetic bone and joint infection, 1634 patients were included (580 patients SPECT, 1054 patients FDG-PET). Level of evidence (Oxford criteria) was 2-3b. For SPECT, the highest diagnostic accuracy of 95% for diagnosis of bone and joint infections is achieved with combined (111)In-WBC and (99m)Tc-sulfur colloid. Acceptable diagnostic accuracy was also obtained with (99m)Tc-WBC or (111)In-WBC combined with (99m)Tc-methylene diphosphonate ((99m)Tc-MDP). FDG-PET is useful for diagnosis of osteomyelitis with a sensitivity and specificity generally over 95%. In patients with orthopedic implant infections, sensitivity varies widely from 28% to 91% and specificity from 9% to 97%. This variation in FDG-PET performance in orthopedic implant infections depends largely on the (use of different) criteria to diagnose infection. Determination of the best criteria is still a matter of debate. CONCLUSIONS SPECT/computed tomography (CT) with (111)In-WBC combined with (99m)Tc-MDP or (99m)Tc-sulfur colloid seems to be the best imaging technique for diagnosis of bone and joint infections. FDG-PET is also useful for diagnosis of osteomyelitis with improved spatial resolution over SPECT imaging, allowing more accurate localization. Localization can be further improved by adding CT. Diagnosis of orthopedic implant infections with FDG-PET depends strongly on the localization of the implant and the criteria used to diagnose infection. Confirmation of well defined criteria to diagnose infection on FDG-PET in patients with metallic implants is thus of paramount importance for optimal diagnosis.
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Affiliation(s)
- Wouter van der Bruggen
- Department of Nuclear Medicine, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
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Chen K, Blebea J, Laredo JD, Chen W, Alavi A, Torigian DA. Evaluation of Musculoskeletal Disorders with PET, PET/CT, and PET/MR Imaging. PET Clin 2009; 3:451-65. [PMID: 27156671 DOI: 10.1016/j.cpet.2009.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
18F-2-fluoro-2-deoxy-D-glucose-PET has an established role in the evaluation of hip periprosthetic infection and musculoskeletal malignancies. Determination of its role in the management of inflammatory arthritis and diabetic foot complications is ongoing. The reintroduction of fluorine F 18 sodium fluoride as a PET radiotracer may advantageously replace technetium Tc 99 m methylene diphosphonate for some non-oncologic applications, including treatment monitoring of Paget's disease andfibrous dysplasia. The combination of CT or MR imaging with PET imaging synergistically maximizes the diagnostic potential of a combined structural-functional imaging approach for the detection, characterization, and monitoring of myriad musculoskeletal disorders.
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Affiliation(s)
- Karen Chen
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - Judy Blebea
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Jean-Denis Laredo
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Wengen Chen
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Abass Alavi
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Drew A Torigian
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
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FDG-PET for diagnosing prosthetic joint infection: systematic review and metaanalysis. Eur J Nucl Med Mol Imaging 2009; 35:2122-32. [PMID: 18704405 DOI: 10.1007/s00259-008-0887-x] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The aim of this study was to systematically review and metaanalyze published data on the diagnostic performance of (18)F-fluoro-2-deoxyglucose positron emission tomography (FDG-PET) in detecting prosthetic hip or knee joint infection. METHODS A systematic search for relevant studies was performed of the PubMed/MEDLINE and Embase databases. Two reviewers independently assessed the methodological quality of each study. A metaanalysis of the reported sensitivity and specificity of each study was performed. Subgroup analyses were performed if results of individual studies were heterogeneous. RESULTS The inclusion criteria were met by 11 studies; there was a total sample size of 635 prostheses. Overall, the studies had good methodological quality. Pooled sensitivity and specificity of FDG-PET for the detection of prosthetic hip or knee joint infection were 82.1% (95%CI = 68.0-90.8%) and 86.6% (95%CI = 79.7-91.4%), respectively. Heterogeneity among the results of individual studies was present (I (2) = 68.8%). Diagnostic performance was influenced by type of joint prostheses (hip prostheses vs. knee prostheses) and type of reconstruction method used (filtered back vs. iterative) (p = 0.0164 and p = 0.0235, respectively). CONCLUSION In this metaanalysis, overall diagnostic performance of FDG-PET was moderate to high. Caution is warranted, however, because results of individual studies were heterogeneous and could not be fully explored. Future studies should further explore potential causes of heterogeneity and validate the use of FDG-PET for diagnosing prosthetic joint infection.
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