Three-phase Bone Scintigraphy Research Articles

Rational and reliable diagnosis of periprosthetic hip and knee joint infection using two nuclear-medicine methods: 99mtc-ciprofloxacin and 99mTc-MDP scintigraphy

Background/Aim. There is a constant and dramatic in-crease in hip and knee prosthetic implantations worldwide. However, a decrease in the percentage of failed (infected) prosthetic implantations is not significant (0.5% up to 2%). The real challenge is whether prosthetic joint loosening was caused by aseptic inflammation or by infection. The aim of the present study was to attempt to distinguish sterile inflammation from infection in patients with a painful hip or knee prosthetic joint. Another objective was to determine the accuracy of cumulative bone scintigraphy with methylenediphosphonate (MDP) and ciprofloxacin in diagnosis of periprosthetic joint infection (PJI). Methods. Three-phase bone scintigraphy with 99mTc-MDP and 99mTc-ciprofloxacin was used. The patient selection criterion for this study was a suspicion of PJI followed by painful and limited movement of the prosthetic joint, accompanied by elevated unspecific inflammatory factors. Forty five patients with 39 implanted hips and 24 knee prostheses were included and evaluated. All prosthetic joints were examined (although some of them were asymptomatic) and underwent plain radiography. An average time span between the two nuclear medicine imaging procedures was 3?5 days. Three-phase 99mTc-MDP bone scintigraphy was performed first. Scintigraphy with 99mTc-ciprofloxacin was necessarily involved calculation of the accumulation index. The obtained results were confirmed by microbiological findings as a gold standard. Statistical analysis of the results was performed using SPSS version 20 software (descriptive statistics, ?2-test). Sensitivity, specificity, and predictive values were also calculated. Results. Microbiologically confirmed PJI was found in 16 out of 39 hip prostheses. Positive scintigraphy was obtained in 15 out of 39 prosthetic hip joints. PJI was found using scintigraphy of the knee, and microbiologically con-firmed in all 13 out of 24 suspected joints. Estimated sensitivity/specificity of 99mTc-MDP bone scintigraphy alone (for both joints) was 90%/69%, for 99mTc-ciprofloxacin scintigraphy it was 93%/97%, and for cumulative results it was 96.5%/97%. Conclusion. Cumulative 99mTc-MDP scintigraphy with 99mTc-ciprofloxacin scintigraphy increases the ability of differentiation between aseptic loosening and PJI, with high accuracy of 97%.

DIAGNOSTIC ROLE OF BONE SCINTIGRAPHY IN EARLY PROGNOSIS OF PARAENDOPROSTHETIC COMPLICATIONS IN ARTHROPLASTY OF HIP AND KNIEE JOINTS

For 10 years, we studied the diagnostic role of three-phase bone scintigraphy (3-f BS) in the early prognosis of paraendoprosthetic complications in patients with degenerative-dystrophic and infectious-inflammatory diseases of the hip and knee joints. Using 3-f BS, the kinetic radionuclide parameters of inclusion and distribution of radiopharmaceutical (RP) in the projection of affected joints were evaluated. It was determined that the kinetics of osteotropic RP in the foci of fixation of affected joints in infectious and inflammatory processes is characterized by the predominance of retention and specific accumulation of the drug in the early and delayed static phase of 3-f BS in comparison with foci of fixing RP in degenerative-dystrophic lesions, which correlates with the differences destructively-reparative processes in them.According to the results of the analysis of the kinetic parameters, a radionuclide model of the dynamics of inclusion and distribution of RP in septic and aseptic joint lesions has been developed.

DIAGNOSTIC ROLE OF BONE SCINTIGRAPHY IN EARLY PROGNOSIS OF PARAENDOPROSTHETIC COMPLICATIONS IN ARTHROPLASTY OF HIP AND KNIEE JOINTS

For 10 years, we studied the diagnostic role of three-phase bone scintigraphy (3-f BS) in the early prognosis of paraendoprosthetic complications in patients with degenerative-dystrophic and infectious-inflammatory diseases of the hip and knee joints. Using 3-f BS, the kinetic radionuclide parameters of inclusion and distribution of radiopharmaceutical (RP) in the projection of affected joints were evaluated. It was determined that the kinetics of osteotropic RP in the foci of fixation of affected joints in infectious and inflammatory processes is characterized by the predominance of retention and specific accumulation of the drug in the early and delayed static phase of 3-f BS in comparison with foci of fixing RP in degenerative-dystrophic lesions, which correlates with the differences destructively-reparative processes in them.According to the results of the analysis of the kinetic parameters, a radionuclide model of the dynamics of inclusion and distribution of RP in septic and aseptic joint lesions has been developed.

Bone SPECT/CT imaging of a liposclerosing myxofibroid tumor in an unexpected localization

BackgroundThe combination of both functional and morphological information using three-phase bone scintigraphy and tomographic imaging with single photon emission tomography/computed tomography (SPECT/CT) allows precise characterization of most bone lesions. The hybrid imaging is most useful when conventional imaging is equivocal or contraindicated (e.g magnetic resonance imaging (MRI).Case presentationA 69-year old, male patient with moderate pain in his posterior pelvic region was diagnosed with an unclear tumor of the iliac bone. Conventional radiographs, computed tomography (CT), and MRI imaging were inconclusive to confirm or refute a malignant process. There was no abnormal hyperperfusion on the early images. On the delayed images, moderately increased osteoblastic activity was noted, and the provisional diagnosis was in favor of a benign process. Histopathology confirmed a benign liposclerosing myxofibrous tumor located in the left iliac bone.ConclusionBone scan SPECT/CT might (a) help in classifying bone lesions by combining their metabolic and morphological (e.g CT) characteristics and (b), might help in discriminating benign and malignant tumors.

Earlier Phases of Bone Scintigraphy Can Better Delineate the Extent of Soft Tissue Involvement of Bone Metastasis

Three-phase bone scintigraphy is sometimes of great value in the detection of uncharacteristic metastases and assists the management of patients in terms of primary focus detection. While evaluating the skeletal system with whole-body bone scintigraphy, other system pathologies may also be detected incidentally. In this case, we present the extraordinary findings on the 3-phase MDP bone scintigraphy and F-FDG PET/CT imaging of the complicated bone metastases in a patient with thyroid carcinoma.

Additive value of 99mTechnetium methylene diphosphonate hybrid single-photon emission computed tomography/computed tomography in the diagnosis of skull base osteomyelitis in otitis externa patients compared to planar bone scintigraphy.

The aim of this study was to evaluate the additive value of 99mtechnetium methylene diphosphonate (99mTc-MDP) hybrid single-photon emission computed tomography/computed tomography (SPECT-CT) in the diagnosis of skull base osteomyelitis (SBO) compared to planar bone scintigraphy (PBS). This was a single institution; prospective study included 23 patients with otitis externa, clinically suspected of SBO, all of them were diabetic. Three-phase bone scintigraphy and SPECT/CT were performed to all patients. The imaging modalities which had the most equivocal results were PBS (9/23) followed by SPECT (3/23). No equivocal results were detected with CT or SPECT-CT. SPECT-CT had the highest sensitivity (100%) and highest accuracy (95.7%) in diagnosis of SBO, whereas, PBS showed the lowest sensitivity (50%) and lowest accuracy (52.2%). In this study, SPECT-CT considered the best modality for accurate localization of the site of SBO involvement, followed by CT. SPECT and planar BS were less accurate in this consideration. When comparing the sensitivity of planar BS, CT, SPECT and SPECT/CT, statistical significance difference was detected between planar BS and SPECT (P = 0.057), planar BS and SPECT/CT (P = 0.001), and between CT and SPECT/CT (P = 0.031). No statistically significant difference was detected between SPECT and SPECT/CT (P = 0.250), CT and planar BS (P = 0.125), and between CT and SPECT (P = 0.508) In conclusion, 99Tc-MDP SPECT/CT has high sensitivity in the diagnosis of SBO and also provide accurate localization of the site of SBO.

Three-phase Bone Scintigraphy Can Predict the Analgesic Efficacy of Ketamine Therapy in CRPS.

The efficacy of ketamine in relieving complex regional pain syndrome (CRPS) lacks predictive factors. The value of three-phase bone scintigraphy (TPBS) was assessed for this purpose. TPBS was performed in 105 patients with unilateral, focal CRPS of type 1 before 5 days of ketamine infusions. Tracer uptake was measured in the region of interest concerned by CRPS and the contralateral homologous region. For the 3 scintigraphic phases (vascular, tissular, and bone phases), an asymmetry ratio of fixation was calculated between the affected and the unaffected sides (vascular phase [VPr], tissular phase [TPr], and bone phase [BPr]). Ketamine efficacy was assessed on pain intensity scores. Ketamine-induced pain relief did not correlate with VPr, TPr, and BPr, but with the ratios of these ratios: BPr/TPr (r=0.32, P=0.009), BPr/VPr (r=0.34, P=0.005), and TPr/VPr (r=0.23, P=0.02). The optimum cut-off value for predicting the response to ketamine therapy was >1.125 for BPr/TPr, >1.075 for BPr/VPr, and >0.935 for TPr/VPr. The combination of increased values of BPr/TPr, BPr/VPr, and TPr/VPr was highly significantly associated with ketamine therapy outcome. The relative hyperfixation of the radioactive tracer in the limb region concerned by CRPS in phases 2 and 3 versus phase 1 of TPBS correlated positively to the analgesic efficacy of ketamine. This study shows for the first time the potential predictive value of TPBS regarding ketamine therapy outcome. In addition, these results suggest that the analgesic action of ketamine is not restricted to "central" mechanisms, but may also involve "peripheral" mechanisms related to tissue inflammation and bone remodeling.

Prevalence and Risk Factors of Atypical Femoral Fracture Bone Scintigraphic Feature in Patients Experiencing Bisphosphonate-Related Osteonecrosis of the Jaw.

Bisphosphonate (BP) is the first-line therapy for the management of osteoporosis. BP-related osteonecrosis of the jaw (BRONJ) and atypical femoral fracture (AFF) are increasingly common comorbidities in patients with osteoporosis under long-term BP treatment. The aim of this study was to evaluate the incidence and risk factors for AFF features on bone scintigraphy in patients with BRONJ. Among total of 373 BRONJ patients treated between September 2005 and July 2014, 237 (220 women, 17 men; median age 73years) who underwent three-phase bone scintigraphy were enrolled for this retrospective study. AFF features on bone scintigraphy and the related clinical factors were assessed. Among 237 patients with BRONJ, 11 (4.6%) showed AFF features on bone scintigraphy. BP medication duration (p = 0.049) correlated significantly with AFF features on bone scintigraphy in patients with BRONJ. BP intake duration of 34months was the cutoff value for predicting the presence of AFF features on bone scintigraphy. Among the patients with BRONJ, all those with AFF features on bone scintigraphy were female patients with osteoporosis who were on oral BP medication; however, these factors were not significantly different along with AFF features on bone scintigraphy. The incidence of AFF features on bone scintigraphy was relatively high in patients with BRONJ. A careful observation of patients presenting with the AFF features on bone scintigraphy may be needed, particularly for female BRONJ patients with osteoporosis who have been on BP medication for over 34months.

Utility of Radionuclide Bone Scintigraphy in Complex Regional Pain Syndrome.

To describe the current understanding of the role of three-phase bone scintigraphy (TPBS) in the diagnosis and management of complex regional pain syndrome (CRPS), discuss its advantages and limitations, and present three examples of TPBS patterns typically seen in CRPS patients. CRPS is a debilitating disorder frequently presenting with pain to ordinarily non-painful stimuli, redness, swelling, following fractures, stroke, myocardial infarction, surgery, or even minor trauma, and its diagnosis, based on clinical criteria and supportive imaging findings, is difficult. Of the available adjunctive diagnostic imaging modalities, radionuclide bone scintigraphy using a TPBS protocol is the most sensitive and specific for detecting abnormalities commonly seen with this condition-classically, increased periarticular uptake on delayed phase of TPBS, with variable increased uptake on perfusion phases, depending on chronicity. Recent studies have (1) demonstrated a more heterogeneous correlation of TPBS findings with CRPS diagnosis using the current Budapest criteria than in studies using older criteria, (2) pointed to the utility of novel quantitative scintigraphic techniques, and (3) highlighted the value of the early perfusion phases of TPBS in predicting treatment response. TPBS remains a valuable imaging adjunct to clinical diagnosis of CRPS. In combination with a multi-modal analgesic approach, TPBS can be used to follow disease course and potentially treatment response, although prospective trials are needed to further delineate its role.

Complex Regional Pain Syndrome of Non-hemiplegic Upper Limb in a Stroke Patient: A Case Report.

Complex regional pain syndrome (CRPS) type I in stroke patients is usually known to affect the hemiplegic upper limb. We report a case of CRPS presented in an ipsilesional arm of a 72-year-old female patient after an ischemic stroke at the left middle cerebral artery territory. Clinical signs such as painful range of motion and hyperalgesia of her left upper extremity, swollen left hand, and dystonic posture were suggestive of CRPS. A three-phase bone scintigraphy showed increased uptake in all phases in the ipsilesional arm. Diffusion tensor tractography showed significantly decreased fiber numbers of the corticospinal tract and the spinothalamic tract in both unaffected and affected hemispheres. Pain and range of motion of the left arm of the patient improved after oral steroids with a starting dose of 50 mg/day.

PREDICTION OF PARANENDOPROSTHETIC COMPLICATIONS OF PATIENTS WITH THE PATHOLOGY OF HIP AND KNEE JOINTS OF VARIOUS GENESIS

Relevance. The issue of degenerative-dystrophic lesions of the hip and knee joints is becoming urgent in Ukraine. To date, in order to visualize degenerative-dystrophic and infectious-inflammatory lesions in the treatment and diagnostic process, the three-phase bone scintigraphy method is actively used, with the help of which it is possible to obtain a quantitative characteristic of metabolic changes and the morphological status of the organism.
 Objective. To determine the specific radionuclide parameters of three-phase bone scintigraphy for optimizing the prediction of paraendoprosthetic complications in pathological lesions of hip and knee joints of different genesis.
 Material and methods. The retrospective analysis of 455 patients with diseases of hip and knee joints of various genesis (including 274 women and 181 men), aged from 17 to 85 years, was conducted in the work. All patients underwent three-phase bone scintigraphy according to the standard protocol.
 Results. In the early static phase of bone scintigraphy, a gradual increase in the percentage of inclusion and distribution of radiopharmaceutical in degenerative-dystrophic and infectious-inflammatory foci is observed. The increase in accumulation of the indicator in the delayed static phase in the infectious-inflammatory foci of deforming osteoarthrosis is caused by an increase in the intensity of blood flow in the angiographic phase, which indicated the intensification of the arterial blood supply of such foci, due to active inflammation, exposure to an infectious agent or increased osteoblastic activity.
 Conclusion. The determination of the kinetic parameters of bone scintigraphy and the application of the radionuclide model of «dual time point imaging» contribute to the early detection of paraendoprosthetic complications in the postoperative period, the reduction of the number of revision procedures and the reduction in the duration of rehabilitation and recovery measures after endoprosthetics.

Bone scintigraphy in patients with pain.

Nuclear medicine imaging is widely used in pain medicine. Low back pain is commonly encountered by physicians, with its prevalence from 49% to 70%. Computed tomography (CT) or magnetic resonance imaging (MRI) are usually used to evaluate the cause of low back pain, however, these findings from these scans could also be observed in asymptomatic patients. Bone scintigraphy has an additional value in patients with low back pain. Complex regional pain syndrome (CRPS) is defined as a painful disorder of the extremities, which is characterized by sensory, autonomic, vasomotor, and trophic disturbances. To assist the diagnosis of CRPS, three-phase bone scintigraphy is thought to be superior compared to other modalities, and could be used to rule out CRPS due to its high specificity. Studies regarding the effect of bone scintigraphy in patients with extremity pain have not been widely conducted. Ultrasound, CT and MRI are widely used imaging modalities for evaluating extremity pain. However, SPECT/CT has an additional role in assessing pain in the extremities.

The Role of Imaging in Childhood Osteomyelitis

: Osteomyelitis in childhood can be a challenging diagnosis. Imaging plays an important role in the diagnosis of osteomyelitis in children, and the imaging findings are crucial in the treatment decision. Pediatric hematogenous osteomyelitis may have variable radiological expression, which is influenced by the age and condition of the patient, the virulence of the causative agent, the stage of the disease, or the selected imaging tool. Different imaging modalities exist for imaging of osteomyelitis which include: conventional radiography, Three-phase bone scintigraphy, ultrasound (US), computed tomography (CT) and magnetic resonance (MR) imaging. Conventional radiography is the initial step in evaluation of osseous changes. In most cases it will be the only imaging technique used in the diagnosis, as well as treatment. Ultrasonography, is a very useful modality. It allows correlating the physical exam with US findings and comparing the affected side with the opposite side. After conventional imaging MRI is the most important imaging modality for the evaluation of osteomyelitis. MRI excellent delineation of the osseous component as well as, soft tissue extension, joint effusion and complications of osteomyelitis such as abscess formation, especially in case of failure to respond to therapy. CT scan is more useful and superior to MR in detecting cortical destruction, air and sequesters. Bone scintigraphy using 99Tc methylene diphosphonate may help to confirm suspected osteomyelitis by showing increased uptake in all three phases of the dynamic perfusion.

Complex Regional Pain Syndrome Type 1: Analysis of 108 Patients

IntroductionComplex regional pain syndrome (CRPS) type 1 is characterized by the presence of pain, edema, functional impotence, impaired mobility, trophic changes, vasomotor instability and bone demineralization. Material and methodsWe carried out a retrospective and prospective, descriptive, observational study of 108 patients over 18 years of age with suspected CRPS who met Doury's criteria. We recorded demographic data, clinical characteristics, comorbidities, previous predisposing conditions and triggering factors, such as injury or fracture. We evaluated laboratory data, serial plain X-rays, 3-phase bone scintigraphy with technetium 99 and bone density scan, as well as drug treatment, rehabilitation and disease course. ResultsIn all, 89% of the 108 patients were women with an average age of 54.8±12.4 years. The time between the onset of the symptoms and the first visit to a physician was 3.1 months. The most common triggering factor was injury (91.7%). The most frequent psychological factor was anxiety (42.6%). All the patients reported pain and 99.07% had impaired mobility. The most frequently affected part of the body was the hand (75%; 81/108 patients) followed by the shoulder, in the shoulder-hand syndrome. All the patients had serial X-rays and changes were observed in 93.5%. Three-phase bone scintigraphy revealed evidence of disease in all 32 of the patients who underwent this study. Bone density scanning was performed in 54 patients (50%). All the patients were treated with nonsteroidal anti-inflammatory drugs, mainly diclofenac (60%). Calcium therapy was initiated in 106 patients (98.2%) and vitamin D3 therapy in 97.2%. All the patients received bisphosphonates, primarily alendronate and ibandronate (67.6% and 27.8%, respectively). Thirty-six patients (33.3%) received corticosteroids. All of the evaluated patients underwent rehabilitation involving occupational therapy. The average time to recovery was 6.31 months (range, 4–24). The outcome was favorable in 88.9% of the patients. ConclusionThis paper describes the clinical characteristics, therapeutic features and outcome of CRPS type 1 in 108 patients. This syndrome is known to be heterogeneous, and does not always present with the well-known symptoms. We recommend establishing a differential diagnosis including other infectious and inflammatory conditions, and point out the importance of early referral, which enables early treatment.

The role of three-phase 99mTc-MDP bone scintigraphy in the diagnosis of periprosthetic joint infection of the hip and knee

Background/Aim. In the last five decades primary hip and knee arthroplasty is the most common and effective surgical intervention worldwide. Infection, although unfrequented, is the most serious complication. Nuclear medicine imaging, not affected by metallic hardware, is the current imaging modality of choice for the evaluation of suspected joint replacement infection. The aim of this study was to estimate the diagnostic accuracy of three phase 99m technetium methylene diphosphonate (99mTc-MDP) bone scintigraphy in periprosthetic hip and knee joint infection. Methods. Inclusion criteria of patients in the study were suspected knee or hip periprosthetic joint infections. In this study, we examined 45 patients (14 men and 31 women) with 39 hip and 24 knee prosthesis (total 63). In all patients, three-phase bone scintigraphy was performed after intravenous application of 555 MBq of 99mTc-MDP. The final confirmation of infection was microbiological or pathohistology finding. Results. Infection was confirmed in 29 prosthetic joints, in 13 (44.8%) knee and 16 (55.2%) hip joints while there was no infection in 34 prosthetic joints. The connection of different modalities of negative and positive findings 99mTc-MDP three-phase bone scintigraphy with the final confirmation of infection showed a high statistical significance (p < 0.001). Three phase bone scintigraphy showed a high sensitivity of 90% but a modest specificity of 69.7% in the detection of periprosthetic infection with the diagnostic accuracy of 79%. The calculated positive predictive value was 73% but the negative predictive value was high 89%. Our results of three-phase bone scintigraphy with calculated sensitivity, specificity and diagnostic accuracy of 79% are in consent with the majority of published studies, or even slightly better. Conclusion. Bone scintigraphy is sensitive in the diagnosis of periprosthetic infection but insufficiently specific. In the detection of periprosthetic infections three-phase bone scan can be used as a diagnostic method of the first line only aimed at its exclusion. The only reasonable use of bone scintigraphy is in combination with other radionuclide methods with high specificity.

Bone Scan in Evaluation of Bone Viability in Severe Frostbite of the Hand.

A 39-year-old male presented to the emergency department (ED) with frostbite to the fingers of both hands. In the ED, he received warm baths, acetylsalicylic acid, clopidogrel, and heparin. A three-phase bone scintigraphy with technetium-99m-methylene diphosphonate revealed absent radiotracer uptake in distal phalanges of both hands. The patient received acetylsalicylic acid, clopidogrel and wound care for the next 5 days and made an excellent recovery with satisfactory wound healing in both hands. Early rapid rewarming and reperfusion can improve the prognosis significantly and therefore bone scan done within first 1–2 days may give spurious results.

Combined bone scintigraphy with 99mTc-MDP and 99mTc-ciprofloxacin in differentiation of hip and knee prosthesis aseptic loosening and infection: A preliminary study

Background/Aim. Although the number of new primary implantation of hip and knee prostheses every year increases, the rate of failed arthroplasty is nearly the same. The main question is whether it is an aseptic instability or instability caused by infection. The aim of this preliminary study was an attempt with combined 99mTc-ciprofloxacin and 99mTc-methylene diphosphonate (MDP) bone scintigraphy to improve diagnostic accuracy in the differentiation of hip and knee prosthesis aseptic loosening and periprosthetic joint infection. Methods. Inclusion criteria of patients for this study were based on suspected periprosthetic joint infection: painful prosthetic joint, restricted joint movements and increased value of erythrocyte sedimentation rate or levels of C-reactive protein. We examined 20 patients with implanted 14 hip and 6 knee prosthesis. All patients also underwent plain radiography of suspected joint. In all patients, three-phase 99mTc-MDP bone scintigraphy was performed. Three to five days after the bone scan, we performed scintigraphy using 99mTc-ciprofloxacin with the calculation of accumulation index. Periprosthetic joint infection was confirmed on the basis of microbiological findings. Results. Periprosthetic joint infection was confirmed in fourteen of twenty observed joints, in five of them the aseptic loosening was present and in one patient?s symptoms were not related to the prosthesis (poor biomechanics of prosthetic joints caused by weaknesses of muscle). Estimated sensitivity/specificity for 99mTc-MDP bone scintigraphy alone were 100/17%; for 99mTc-ciprofloxacin scintigraphy were 85,7/100%. Sensitivity and specificity were 92,3% and 83,3%, respectively for results obtained with combined assessment by both methods. Our study confirmed the high negative predictive value of 99mTc-MDP bone scan. The negative result of bone scan virtually excludes the possibility of periprosthetic infection. On the other hand, positive findings of 99mTc-MDP scintigraphy cannot with certainty confirm the infection. Conclusion. Combined 99mTc-MDP scintigraphy with 99mTc-ciprofloxacin scintigraphy significantly increases the ability of differentiation of aseptic loosening from periprosthetic joint infection.

The role of three-phase bone scintigraphy in arthroplasty of hip and knee joints of clean-up workers of Chornobyl accident

The objective of the work to determine the diagnostic role of the three phase bone scintigraphy (3 F BS) in the early prediction of paraendoprosthetic complications of the hip and knee joints of the participants in clean up workers of Chornobyl accident. The 3 F BS method were investigated the radionuclide kinetic parameters of the inclusion and distribution of radiopharmaceuticals (RF) in damaged joints in the 75 male clean up workers. It was established that calculating the quantitative indices of kinetics of the drug at various stages of the 3 F BS allowed to determine statistically significant differences in metabolic changes in focal lesions in articular structures. Thus, the differential diagnostic capabilities of the radionuclide method of examination of patients with arthroplasty of the hip and knee joints are elevated. The kinetics of osteotropic RF in the foci of fixing the damaged hip and knee joints in the infectious and inflammatory processes is characterized by the predominance of retention and specific accumulation of the drug in the early static phase and the delayed static phase of the 3 F BS compared with the centers of fixation of RF in deforming osteoarthroses, which correlates with the differences in destructive reparative processes in them.

Síndrome doloroso regional complejo tipo 1. Análisis de 108 pacientes

IntroductionComplex regional pain syndrome (CRPS) type 1 is characterized by the presence of pain, edema, functional impotence, impaired mobility, trophic changes, vasomotor instability and bone demineralization. Material and methodsWe carried out a retrospective and prospective, descriptive, observational study of 108 patients over 18 years of age with suspected CRPS who met Doury's criteria. We recorded demographic data, clinical characteristics, comorbidities, previous predisposing conditions and triggering factors, such as injury or fracture. We evaluated laboratory data, serial plain X-rays, 3-phase bone scintigraphy with technetium 99 and bone density scan, as well as drug treatment, rehabilitation and disease course. ResultsIn all, 89% of the 108 patients were women with an average age of 54.8±12.4 years. The time between the onset of the symptoms and the first visit to a physician was 3.1 months. The most common triggering factor was injury (91.7%). The most frequent psychological factor was anxiety (42.6%). All the patients reported pain and 99.07% had impaired mobility. The most frequently affected part of the body was the hand (75%; 81/108 patients) followed by the shoulder, in the shoulder-hand syndrome. All the patients had serial X-rays and changes were observed in 93.5%. Three-phase bone scintigraphy revealed evidence of disease in all 32 of the patients who underwent this study. Bone density scanning was performed in 54 patients (50%). All the patients were treated with nonsteroidal anti-inflammatory drugs, mainly diclofenac (60%). Calcium therapy was initiated in 106 patients (98.2%) and vitamin D3 therapy in 97.2%. All the patients received bisphosphonates, primarily alendronate and ibandronate (67.6% and 27.8%, respectively). Thirty-six patients (33.3%) received corticosteroids. All of the evaluated patients underwent rehabilitation involving occupational therapy. The average time to recovery was 6.31 months (range, 4-24). The outcome was favorable in 88.9% of the patients. ConclusionThis paper describes the clinical characteristics, therapeutic features and outcome of CRPS type 1 in 108 patients. This syndrome is known to be heterogeneous, and does not always present with the well-known symptoms. We recommend establishing a differential diagnosis including other infectious and inflammatory conditions, and point out the importance of early referral, which enables early treatment.

Downregulation of PHEX in multibacillary leprosy patients: observational cross-sectional study.

BackgroundPeripheral nerve injury and bone lesions, well known leprosy complications, lead to deformities and incapacities. The phosphate-regulating gene with homologies to endopeptidase on the X chromosome (PHEX) encodes a homonymous protein (PHEX) implicated in bone metabolism. PHEX/PHEX alterations may result in bone and cartilage lesions. PHEX expression is downregulated by intracellular Mycobacterium leprae (M. leprae) in cultures of human Schwann cells and osteoblasts. M. leprae in vivo effect on PHEX/PHEX is not known.MethodsCross-sectional observational study of 36 leprosy patients (22 lepromatous and 14 borderline-tuberculoid) and 20 healthy volunteers (HV). The following tests were performed: PHEX flow cytometric analysis on blood mononuclear cells, cytokine production in culture supernatant, 25-hydroxyvitamin D (OHvitD) serum levels and 99mTc-MDP three-phase bone scintigraphy, radiography of upper and lower extremities and blood and urine biochemistry.ResultsSignificantly lower PHEX expression levels were observed in lepromatous patients than in the other groups (χ2 = 16.554, p < 0.001 for lymphocytes and χ2 = 13.933, p = 0.001 for monocytes). Low levels of 25-(OHvitD) were observed in HV (median = 23.0 ng/mL) and BT patients (median = 27.5 ng/mL) and normal serum levels were found in LL patients (median = 38.6 ng/mL). Inflammatory cytokines, such as TNF, a PHEX transcription repressor, were lower after stimulation with M. leprae in peripheral blood mononuclear cells from lepromatous in comparison to BT patients and HV (χ2 = 10.820, p < 0.001).ConclusionDownregulation of PHEX may constitute an important early component of bone loss and joint damage in leprosy. The present results suggest a direct effect produced by M. leprae on the osteoarticular system that may use this mechanism.Electronic supplementary materialThe online version of this article (doi:10.1186/s12967-015-0651-5) contains supplementary material, which is available to authorized users.