Diagnostic patterns for bone marrow oedema syndrome and avascular necrosis of the femoral head in dynamic bone scintigraphy

Incremental value of 99mTc-MDP hybrid SPECT/CT over planar scintigraphy and SPECT in avascular necrosis of the femoral head

OBJECTIVE

The aim of the study was to evaluate the incremental value of technetium-99m-methylene diphosphonate (99mTc-MDP) single-photon emission tomography/computed tomography (SPECT/CT) over planar bone scintigraphy (BS) and SPECT in the diagnosis of avascular necrosis (AVN) of the femoral head.

MATERIALS AND METHODS

The data of 44 patients (mean age 36 ± 16 years, 34 male and 10 female) who underwent 99mTc-MDP BS along with regional SPECT/CT for suspected femoral head AVN were retrospectively evaluated. Planar BS, SPECT and SPECT/CT images were evaluated by two nuclear medicine physicians in consensus. On the basis of diagnostic confidence, a score of 1-5 was given, with 1 being definitely AVN, 2 being probably AVN, 3 being equivocal, 4 being probably normal and 5 being definitely normal. Receiver operating characteristic analysis was performed and the area under the curve was calculated. For calculation of sensitivity, specificity and predictive values for planar, an interpretive score of less than or equal to 2 was taken as AVN and a score of 3 or more was taken as no AVN. Clinical and imaging follow-up and histopathological results were taken as the reference standard.

RESULTS

Among 44 patients with 64 affected femoral heads, there were 48 true-positive, 13 true-negative, two false-positive and one false-negative lesion on SPECT/CT. The diagnostic accuracy of planar BS, SPECT and SPECT/CT was 67, 78 and 95%, respectively. Planar BS was found to have the lowest sensitivity (75%) and specificity (40%), whereas SPECT/CT had the highest sensitivity (98%) and specificity (87%). The area under the curve was highest for SPECT/CT (0.919), followed by SPECT (0.76) and planar BS (0.567). SPECT/CT was superior to both SPECT (P = 0.02) and planar BS (P < 0.001), whereas SPECT was superior to planar BS (P = 0.03).

CONCLUSION

SPECT/CT is superior to planar BS and SPECT alone for the diagnosis of AVN of the femoral head.

Bone marrow edema syndrome in postpartal women: treatment with iloprost

Bone marrow edema syndrome of the femoral head in pregnant women is a rare disease resulting in disabling coxalgia, beginning in the last 3 months of pregnancy and persisting for several months after parturition. The parenteral administration of the vasoactive drug iloprost constitutes a new approach to the treatment of painful bone marrow edema syndrome of the hip of pregnant women. Six postpartal women (8 hips) with bone marrow edema syndrome of the femoral head were treated with iloprost followed by 3 weeks of partial weight-bearing. Relief from pain, restoration of functional capacity, and normalization of the MRI signal pattern were rapidly achieved, thus avoiding the need for surgical intervention. As the substance is contraindicated in pregnancy, therapy may begin only some days after parturition, with a short discontinuation in breastfeeding.

Iloprost for the treatment of bone marrow edema in the hindfoot

The parenteral application of the vasoactive drug, iloprost, might be a viable option for the treatment of BMES of different origins, especially ischemic ones. In edema that is secondary to osteoarthrosis or stress, the effect of therapy with iloprost depends on the grade of the basic disease. The natural course of the disease, as well as the normalization of the signal pattern of the MRI, seem to be accelerated.

High-energy shock wave treatment of femoral head necrosis in adults

Adults with Stages I to III osteonecrosis of the femoral head present an overall therapeutic challenge. The objective of the current prospective study was to show the effectiveness of high-energy shock wave therapy in treatment of patients with Association Research Circulation Osseous Stage I to Stage III necrosis of the femoral head by assessing clinical and magnetic resonance imaging results. The current study presents the results of 22 patients with femoral head necrosis 1 year after shock wave treatment. The study population consisted of 10 women and 12 men with an average age of 54.9 years (+/- 12.3). The scores achieved on the visual pain analog scale decreased from 8.5 before treatment to 1.2 after 1 year. Simultaneously, the Harris hip score increased from 43.3 to 92 points. Magnetic resonance imaging visualization of a distinct zone of sclerosis around the necrotic area remaining after treatment with extracorporeal shock wave therapy indicated therapeutic failure. The results obtained so far with high-energy shock wave therapy in these patients suggest that this method may offer an alternative to invasive treatment modalities for femoral head necrosis. A noninvasive and moderately priced method then would be available for the treatment of femoral head necrosis in the early stages of the disease process.