The role of Tc-99m MDP and Ga-67 citrate in predicting the cure of osteomyelitis

Current management of skull base osteomyelitis

PURPOSE OF REVIEW

Skull base osteomyelitis (SBO) is a life-threatening condition. Due to an aging and increasingly multimorbid population, clinicians are more often challenged with this disease. Yet, there is no consensus on the optimal diagnostic and follow-up management. This review should aid clinicians in decision-making for their patients.

RECENT FINDINGS

Treatment-resistant otalgia or headache is suspicious of SBO. Pseudomonas aeruginosa remains the most common pathogen but clinicians are challenged with increasing rates of sterile or fungal cultures due to previously applied antibiotics/steroids. No single imaging modality is able to detect the full extent of the disease. Whereas functional nuclear imaging with gallium-67 or methylene diphosphonate-technetium-99m was once advocated, its actual benefit is questionable. Newer modalities such as fluoro-D-glucose-positron emission tomography (PET)/computed tomography, PET/magnetic resonance imaging (MRI), or diffusion-weighted MRI seem to be promising in diagnosis and follow-up. Finding the causative pathogen is of utmost importance followed by long-term intravenous antibiotics until the disease has completely resolved. Surgery plays a minor role in treatment but can be helpful in selected cases.

SUMMARY

The numerous challenges in SBO render management difficult, but with a clear work-up including regular clinical, laboratory and imaging examinations, outcome can be improved.

Work-up of the diabetic foot

Diabetes is a common disease with potentially devastating complications affecting the foot and ankle. A combination of vascular disease, peripheral neuropathy, and immunopathy results in a cascade of conditions including ischemia and infarction, tendinopathy, atrophy, edema, deformity, neuropathic osteoarthropathy, callus, ulceration, and infection. MRI is useful for evaluation of these complications, and assists the clinician in medical or surgical planning.

Treatment of chronic traumatic bone wounds. Microvascular free tissue transfer: a 13-year experience in 96 patients

During a 13-year period at the Massachusetts General Hospital, Boston, Massachusetts, 97 microvascular free tissue transfers have been performed for soft-tissue reconstruction in 96 patients following bone debridement for chronic traumatic bone wounds. These 96 patients comprise a continuation study of 18 original patients reported in 1982. During a 13-year follow-up period (mean, 77.1 months), 95.8% of these 96 patients have enjoyed complete wound closure with a lack of drainage after the debridement and free tissue transfer. Most of the patients (89.6%) encountered in this study are ambulatory without assist and 5.2% of patients have undergone amputation. Twenty-three per cent of patients required subsequent segmental bone defect reconstruction in the lower extremity after infection eradication. The pathophysiology of chronic traumatic bony wounds is different from that of chronic hematogenous osteomyelitis and thus a high incidence of long-term successful management can be seen through complete wound debridement and adequate soft-tissue coverage.

Sequential technetium-99m/gallium-67 scintigraphic evaluation of subclinical osteomyelitis complicating fracture nonunion

Twenty-four patients with a history of post-traumatic fracture nonunion underwent sequential 99mTc and 67Ga citrate scintigraphy in an attempt to differentiate between posttraumatic fracture nonunion and nonunion complicated by subclinical osteomyelitis. Neither technetium nor gallium studies alone nor in combination, with or without clinical correlation, could help delineate between fracture nonunion and nonunion complicated by subclinical osteomyelitis because of the increased technetium and gallium radioisotope uptake associated with the nonunion site.