A Systematic Review and Meta-Analysis on the Accuracy of Fluorodeoxyglucose Positron Emission Tomography/ Computerized Tomography for Diagnosing Periprosthetic Joint Infections

Detection of Synchronous Foci of Infection Using Positron Emission Tomography in Septic Patients Who Have a Periprosthetic Joint Infection

BACKGROUND

Periprosthetic joint infection (PJI) with sepsis is a life-threatening condition and identification of synchronous foci of infection is challenging. Positron emission tomography using 18F-fluorodeoxyglucose combined with computed tomography (18F-FDG-PET/CT) is useful to detect PJI in elective, nonseptic patients. We hypothesized that in patients who have PJI and concomitant sepsis requiring intensive care, 18F-FDG-PET/CT could accurately identify synchronous foci of infection. We addressed the following questions: (1) How often were synchronous foci of infection detected?; (2) What were the confirmation rates of these infection foci by other complementary state-of-the-art methods?; (3) Did 18F-FDG-PET/CT findings result in surgical treatment?; and (4) What is the risk of synchronous PJI in patients who have PJI and concomitant sepsis who have another indwelling arthroplasty?

METHODS

We retrospectively analyzed mechanically ventilated septic PJI patients who underwent 18F-FDG-PET/CT between January 1, 2017 and December 21, 2022. The identified synchronous foci of infection were categorized into musculoskeletal, cardiovascular, pulmonary, or other infections and compared to results from tissue culture, histopathology, magnetic resonance imaging, or transesophageal echocardiography.

RESULTS

We identified 17 eligible patients. The 18F-FDG-PET/CT revealed at least one additional infection focus in 15 patients with the following distribution: musculoskeletal (n = 12), cardiovascular (n = 3), pulmonary (n = 13), and other infections (n = 6). Synchronous foci of infection identified with 18F-FDG-PET/CT were confirmed by another state-of-the-art method in 1 all 15 patients. Diagnoses with 18F-FDG-PET/CT led to additional surgery in 11 patients. Of the patients, 10 of 17 had another arthroplasty with a risk in three of synchronous PJI.

CONCLUSIONS

We highlight the value of 18F-FDG-PET/CT in patients who have PJI and sepsis, emphasizing its role in the comprehensive evaluation of these patients for subsequent therapeutic decision-making.

Osteomyelitis in complicated bones: the role of FDG PET/CT

Osteomyelitis in infections encompasses heterogeneous group of condition that frequently have high morbidity and comes at a huge cost to healthcare system. Accurate and early diagnosis is important for the proper management of the condition. FDG PET/CT has been found useful in the osteomyelitis of complicated bones, including prosthetic joint infections, fracture related infections and sternal wound infections. The altered anatomy and the replacement of marrow in some cases of metallic implant makes the use of anatomic-based methods less optimal. FDG PET/CT has been found to be useful under these circumstances, however, it also has its own limitation of lack of specificity especially due to inflammation. Recent meta-analysis of the role of FDG PET/CT in complicated osteomyelitis have result in the validation defined the indications for its use. This has led to the publication of best use criteria and recommendations of by joint committees of major nuclear medicine societies.

EANM/SNMMI guideline/procedure standard for [18F]FDG hybrid PET use in infection and inflammation in adults v2.0

INTRODUCTION

Hybrid [18F]FDG PET imaging is currently the method of choice for a wide variety of infectious and inflammatory disorders and was recently adopted in several clinical guidelines. A large amount of evidence-based articles, guidelines and appropriate use criteria have been published since the first version of this guideline in 2013.

PURPOSE

To provide updated evidence-based information to assist physicians in recommending, performing and interpreting hybrid [18F]FDG PET examinations for infectious and inflammatory disorders in the adult population.

METHODS

A systematic literature search of evidence-based articles using whole-body [18F]FDG hybrid imaging on the indications covered within this guideline was performed. All systematic reviews and meta-analyses published within the last 10 years until January 2023 were identified in PubMed/Medline or Cochrane. For each indication covered in this manuscript, diagnostic performance was provided based on meta-analyses or systematic reviews. If not available, results from prospective or retrospective studies were considered based on predefined selection criteria. RESULTS AND CONCLUSIONS: Hybrid [18F]FDG PET is extremely useful in the work-up and management of adults with infectious and inflammatory diseases, as supported by extensive and rapidly growing evidence-based literature and adoption in clinical guidelines. Practical recommendations are provided describing evidence-based indications as well as interpretation criteria and pitfalls. Monitoring treatment response is the most challenging but insufficiently studied potential application in infection and inflammation imaging.

Imaging in Periprosthetic Joint Infection Diagnosis: A Comprehensive Review

Various imaging methods assist in diagnosing periprosthetic joint infection (PJI). These include radiological techniques such as radiography, computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound (US); as well as advanced nuclear medicine techniques including bone scintigraphy (BS), anti-granulocyte antibody imaging (AGS), leukocyte scintigraphy (LS), and fluorodeoxyglucose positron emission tomography (FDG-PET and FDG-PET/CT). Each imaging technique and radiopharmaceutical has been extensively studied, with unique diagnostic accuracy, limitations, and benefits for PJI diagnosis. This review aims to detail and describe the most commonly used imaging techniques and radiopharmaceuticals for evaluating PJI, focusing particularly on knee and hip arthroplasties.

Research trends and focus of prosthetic joint infections from 2013 to 2023: bibliometric and visualization studies

Background

Postoperative infections in artificial joints provide considerable difficulties in the field of orthopedics, especially after joint replacement procedures. These infections rank among the most severe postoperative consequences, frequently leading to treatment ineffectiveness and reduced quality of life for surgery patients. Consequently, it is crucial to acquire knowledge about worldwide research trends in this area in order to educate clinical practices and improve therapeutic techniques. This work exploits bibliometric analysis to investigate the present state, developing patterns, and main areas of focus in research on artificial joint infection.

Objective

To analyze the research trends, hotspots, and international collaborations on artificial joint infections worldwide from 2013 to 2023.

Methods

Extractions of raw data were made from the WoSCC (Web of Science Core Collection) database. Detailed information collected includes the quantity of publications, authors, citations, publication year, h-index, references, country/region, journal, and keywords. Analysis of the data was conducted using VOSviewer version 1.6.10.0 and CiteSpace version 6.3.R1.

Results

A total of 1,799 articles published between 2013 and 2023 were included in this analysis, showing a steady increase in publication with the United States leading at 553 articles. Infection rates and topics such as biofilm formation and antimicrobial resistance were highly cited, with Mayo Clinic contributing 65 articles as the most prolific institution.

Conclusion

Research on biofilm infections, antibiotic resistance, and new biomarkers is a key focus, particularly on disrupting biofilms and enhancing diagnostics. There's growing attention in biomarkers like α-defensins and exosomal miRNAs for PJI diagnosis, pointing to new clinical uses. Studies on antimicrobial-coated prosthetics and topical agents are also gaining importance in treatment strategies.

68Ga Radiolabeling of NODASA-Functionalized Phage Display-Derived Peptides for Prospective Assessment as Tuberculosis-Specific PET Radiotracers

This research presents the development of positron emission tomography (PET) radiotracers for detecting Mycobacterium tuberculosis (MTB) for the diagnosis and monitoring of tuberculosis. Two phage display-derived peptides with proven selective binding to MTB were identified for development into PET radiopharmaceuticals: H8 (linear peptide) and PH1 (cyclic peptide). We sought to functionalize H8/PH1 with NODASA, a bifunctional chelator that allows complexation of PET-compatible radiometals such as gallium-68. Herein, we report on the chelator functionalization, optimized radiosynthesis, and assessment of the radiopharmaceutical properties of [68Ga]Ga-NODASA-H8 and [68Ga]Ga-NODASA-PH1. Robust radiolabeling was achieved using the established routine method, indicating consistent production of a radiochemically pure product (RCP ≥ 99.6%). For respective [68Ga]Ga-NODASA-H8 and [68Ga]Ga-NODASA-PH1, relatively high levels of decay-corrected radiochemical yield (91.2% ± 2.3%, 86.7% ± 4.0%) and apparent molar activity (Am, 3.9 ± 0.8 and 34.0 ± 5.3 GBq/μmol) were reliably achieved within 42 min, suitable for imaging purposes. Notably, [68Ga]Ga-NODASA-PH1 remained stable in blood plasma for up to 2 h, while [68Ga]Ga-NODASA-H8 degraded within 30 min. For both 68Ga peptides, minimal whole-blood cell binding and plasma protein binding were observed, indicating a favorable pharmaceutical behavior. [68Ga]Ga-NODASA-PH1 is a promising candidate for further in vitro/in vivo evaluation as a tuberculosis-specific infection imaging agent.

Accuracy of Albumin, Globulin, and Albumin-Globulin Ratio for Diagnosing Periprosthetic Joint Infection: A Systematic Review and Meta-Analysis

Periprosthetic joint infection (PJI) is one of the most intractable orthopedic diseases, partly because of the difficulty in differentiating septic from aseptic conditions. We aimed to evaluate and consolidate the diagnostic accuracy of the quantitative assessment of serum albumin (Alb), globulin (Glb), and albumin-globulin ratio (AGR), alone or in combination with the inflammatory marker, C-reactive protein (CRP), for PJI. We searched the PubMed, CINAHL, and Cochrane Library databases for studies that quantitatively measured Alb, Glb, or AGR for the diagnosis of PJI up until the 30 April 2023. A total of 2339 patients were included from 10 studies, including 845 patients with a definitive diagnosis of PJI and 1494 with non-PJI. The pooled sensitivity, specificity, and area under the curve (AUC) in the summary receiver-operating characteristic curve were as follows: 0.625, 0.732, and 0.715 for Alb; 0.815, 0.857, and 0.887 for Glb; 0.753, 0.757, and 0.875 for AGR; 0.788, 0.837, and 0.876 for CRP; 0.879, 0.890, and 0.917 for the CRP-Alb ratio; and 0.845, 0.855, and 0.908 for the CRP-AGR ratio. Serum Alb, Glb, and AGR levels are feasible and accurate diagnostic markers for PJI, and the combination of these markers with CRP levels may potentially improve preoperative serum diagnostic accuracy. Future prospective studies are required to verify these findings because of the small numbers of included studies.

Diagnostic accuracy of positron emission tomography/computerized tomography for periprosthetic joint infection of hip: systematic review and meta-analysis

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.

Emerging Technologies in Diagnosing Periprosthetic Joint Infections

Periprosthetic joint infection (PJI) is a well-known serious complication following joint replacement surgeries and is responsible for high failure rates of implanted devices. Any delay in the diagnosis can compromise treatment success, putting a huge burden on the patients' wellness and healthcare systems. Diagnosing PJIs is quite complex as there is still no gold standard test to reach the definitive diagnosis in a timely manner. A number of laboratory tests and radiological imaging inventions have evolved in the past few years, requiring consistent updates of the available guidelines to keep up with the latest advances in the field. This article highlights the recent advances in diagnosing PJIs and discusses their validity for use in clinical practice.