Role of nuclear medicine in diagnosis of the infected joint replacement.

Some complications of joint replacement surgery are easily diagnosed; however, differentiating infection from aseptic loosening is difficult because these entities are remarkably similar at clinical and histopathologic examination. Clinical signs and symptoms, laboratory tests, radiography, and joint aspiration are insensitive, nonspecific, or both. Cross-sectional imaging modalities are hampered by artifacts produced by the prosthetic devices themselves. Radionuclide imaging is not affected by the presence of metallic hardware and is therefore useful for evaluating the painful prosthesis. Bone scintigraphy is useful as a screening test, despite an accuracy of only 50%-70%, because normal results essentially exclude a prosthetic complication. The addition of gallium-67, a nonspecific inflammation-imaging agent, improves the accuracy of bone scintigraphy to 70%-80%. The accuracy of combined leukocyte-marrow imaging, 90%, is the highest among available radionuclide studies. Its success is due to the fact that leukocyte imaging is most sensitive for detection of neutrophil-mediated inflammation (ie, infection). The success of leukocyte-marrow imaging is tempered by the limitations of in vitro labeling. In vivo labeling has been investigated, and a murine monoclonal antigranulocyte antibody appears promising. Some investigations have focused on fluorodeoxyglucose imaging. Although this method is sensitive, specificity is a concern.

The diabetic foot.

Foot complications in diabetics often lead to amputation. Ulceration is the most common complication in the diabetic forefoot and underlies more than 90% of cases of pedal osteomyelitis. The diagnosis of osteomyelitis is, nevertheless, difficult, and imaging is an important part of the work-up. Plain radiographs, although useful for anatomical information, are neither sensitive nor specific. Three-phase bone scintigraphy is sensitive but not specific. Labelled leucocyte scintigraphy and MRI are both useful and are complementary to one another. Labelled leucocyte scintigraphy is valuable for diagnosis as well as follow-up of pedal osteomyelitis. MRI offers exquisite anatomical detail, which is invaluable for guiding surgical management. The principal complication in the mid and hind foot is the neuropathic or Charcot joint. Although infection of the neuropathic joint is infrequent, its diagnosis is difficult. The extensive bony changes that accompany this disorder severely diminish the value of radiography and bone scintigraphy. It is not always possible to distinguish the marrow oedema of neuropathy from that of osteomyelitis and the role of MRI in the evaluation of this entity is still uncertain. Uptake of labelled leucocytes in the absence of infection may occur and is owing, at least in part, to haematopoietically active marrow. Combined leucocyte/marrow scintigraphy holds considerable promise for identifying the infected Charcot joint.

Marrow versus infection in the Charcot joint: indium-111 leukocyte and technetium-99m sulfur colloid scintigraphy.

UNLABELLED: This study evaluated the role of combined leukocyte/marrow scintigraphy in the assessment of the neuropathic or Charcot joint. METHODS: Seventeen patients with (111)In-labeled leukocyte accumulation in 20 radiographically confirmed Charcot joints underwent 99mTc-sulfur colloid marrow scintigraphy. Studies demonstrating labeled leukocyte accumulation without corresponding activity on marrow images were classified as positive for osteomyelitis. Six of the patients also underwent three-phase bone scintigraphy. Bone scans were interpreted as positive for osteomyelitis when focal hyperperfusion, focal hyperemia and focal bony uptake on delayed images were present. Bone images were also interpreted together with labeled leukocyte images using two different criteria for a positive study. One criterion was the presence of labeled leukocyte activity in a region demonstrating abnormal activity on the bone scan, which was more intense than adjacent marrow activity or marrow activity in the corresponding region of the contralateral foot. The second criterion was either a spatially incongruent distribution of the two tracers or hyperintense activity on the leukocyte study, as compared to the bone scan. RESULTS: Leukocyte/marrow studies were positive for osteomyelitis in 4 of the 20 neuropathic joints. Osteomyelitis was present in three of the four joints, whereas in the fourth, infection was confined to overlying soft tissues. None of the 16 neuropathic joints with negative leukocyte/marrow scans were infected. In one patient who underwent below-the-knee amputation, histological analysis confirmed the presence of hematopoietically active marrow corresponding to areas of congruent activity on the leukocyte and marrow images. Three-phase bone scintigraphy was positive in all six neuropathic joints studied; osteomyelitis was present in two of them. Using the first criterion, leukocyte/bone imaging was also positive in all six. Using the second criterion, leukocyte/bone imaging was positive in the two infected neuropathic joints, as well as in three uninfected ones. Leukocyte/marrow scintigraphy was positive in both infected joints and negative in the four without infection. CONCLUSION: Labeled leukocyte accumulation in the uninfected Charcot joint does occur and is related, at least in part, to hematopoietically active marrow. Leukocyte/marrow scintigraphy is a reliable way to differentiate between marrow and infection as the cause of labeled leukocyte accumulation in the neuropathic joint and, in this series, was superior to both three-phase bone scintigraphy and combined leukocyte/bone scintigraphy.