Three-phase Bone Scintigraphy Research Articles

Three-phase bone scintigraphy for diagnosis of Charcot neuropathic osteoarthropathy in the diabetic foot - does quantitative data improve diagnostic value?

To investigate whether inclusion of quantitative data on blood flow distribution compared with visual qualitative evaluation improve the reliability and diagnostic performance of 99m Tc-hydroxymethylene diphosphate three-phase bone scintigraphy (TPBS) in patients suspected for charcot neuropathic osteoarthropathy (CNO) of the foot. A retrospective cohort study of TPBS performed on 148 patients with suspected acute CNO referred from a single specialized diabetes care centre. The quantitative blood flow distribution was calculated based on the method described by Deutsch etal. All scintigraphies were re-evaluated by independent, blinded observers twice with and without quantitative data on blood flow distribution at ankle and focus level, respectively. The diagnostic validity of TPBS was determined by subsequent review of clinical data and radiological examinations. A total of 90 patients (61%) had confirmed diagnosis of CNO. The sensitivity, specificity and accuracy of three-phase bone scintigraphy without/with quantitative data were 89%/88%, 58%/62% and 77%/78%, respectively. The intra-observer agreement improved significantly by adding quantitative data in the evaluation (Kappa value 0·79/0·94). The interobserver agreement was not significantly improved. Adding quantitative data on blood flow distribution in the interpretation of TBPS improves intra-observer variation, whereas no difference in interobserver variation was observed. The sensitivity of TPBS in the diagnosis of CNO is high, but holds limited specificity. Diagnostic performance does not improve using quantitative data in the evaluation. This may be due to the reference intervals applied in the study or the absence of a proper gold standard diagnostic procedure for comparison.

Diagnostic value of 99mTc-MDP SPECT/spiral CT combined with three-phase bone scintigraphy in assessing suspected bone tumors in patients with no malignant history.

Three-phase bone scintigraphy using technetium-99m-methylene diphosphonate is used to diagnose skeletal lesions, whereas single-photon emission computed tomography/computed tomography (SPECT/CT) improves the diagnostic accuracy of bone disease. We investigated the usefulness of SPECT/CT combined with three-phase bone scintigraphy over three-phase bone scintigraphy alone in assessing suspected bone tumors in patients with no malignant history. Forty-eight patients (30 men and 18 women; mean age, 43.3 ± 20.1 years; age range, 11-82 years) with suspected bone tumors who underwent technetium-99m-methylene diphosphonate three-phase bone scintigraphy and SPECT/CT between July 2008 and August 2013 were retrospectively reviewed. The lesion from each patient was resected or biopsied for pathological confirmation of the diagnosis within 3 weeks of the bone scan. All images were interpreted by two experienced nuclear medicine physicians who had not been involved in the selection of data for the present study. The reviewers were aware of the patient's sex, age, and the lesion's site but were unaware of the results of other imaging modalities, such as radiography, MRI, and laboratory tests. In cases of discrepancy regarding the interpretations, a consensus was reached after mutual discussion. The diagnostic ability of three-phase bone scintigraphy and SPECT/CT combined with three-phase bone scintigraphy was compared with pathological results using the χ(2)-(test, with P-values less than 0.05 indicating significant differences. Agreement between three-phase bone scintigraphy alone or SPECT/CT combined with three-phase bone scintigraphy with pathological results was evaluated using κ scores. Pathological results from the 48 lesions of all patients revealed 32 malignant bone tumors and 16 benign lesions. On using three-phase bone scintigraphy and SPECT/CT combined with three-phase bone scintigraphy for the differential diagnosis of bone lesions, we found sensitivities to be 96.9 and 100%, specificities to be 31.2 and 81.3%, positive predictive values to be 73.8 and 91.4%, and negative predictive values to be 83.3 and 100%, respectively. The diagnostic accuracies of three-phase bone scintigraphy alone and SPECT/CT combined with three-phase bone scintigraphy were 75.0 and 93.8%, respectively (χ(2) = 5.057; P = 0.025). κ Scores for the agreement of three-phase bone scintigraphy and SPECT/CT combined with three-phase bone scintigraphy with pathological results were 0.333 (P = 0.005) and 0.850 (P < 0.0001), respectively. Compared with three-phase bone scintigraphy, the diagnostic accuracy of SPECT/CT combined with three-phase bone scintigraphy was higher. SPECT/CT combined with three-phase bone scintigraphy is beneficial over three-phase bone scintigraphy for the differential diagnosis of suspected bone tumors in patients with no malignant history.

Increasing Specificity of (99m)Tc-HDP Three-phase bone Scintigraphy and (99m)Tc Besilesomab Scan in Case of Osteomyelitis Complicated with Necrotizing Fasciitis.

Increasing Specificity of (99m)Tc-HDP Three-phase bone Scintigraphy and (99m)Tc Besilesomab Scan in Case of Osteomyelitis Complicated with Necrotizing Fasciitis.

Bone scintigraphy in the diagnosis of Lisfranc fracture

Background: Lisfranc injuries are uncommon and difficult to diagnose. These injuries have a high potential for causing substantial disability related to post-traumatic osteoarthritis and should be managed early to avoid such complications. Lisfranc injuries are frequently missed on radiographs. Hence, bone scanning may be a useful modality in the diagnosis of Lisfranc fracture. Objectives: To investigate the utility of bone scintigraphy in the diagnosis of undiagnosed cases of Lisfranc fracture. Materials and Methods: We studied 13 cases of Lisfranc fracture (8 females and 5males), that were not diagnosed on plain X-ray. Three-phase bone scintigraphy was performed for each patient after administration of 20 mCi (740 MBq) of Tc-99m MDP using a dual-head gamma camera, interfaced with computer. Flow, blood pool and delayed imaging of the feet were performed for each patient, as well as whole body blood pool and delayed images. Results: All the bone scintigraphic studies of the patients showed hyperemia of the affected foot in flow and blood pool studies and focal area of increased uptake at the mid foot region, particularly the tarsometatarsal joint, in the delayed images typical of Lisfranc fracture. However, X-ray of affected foot previously obtained were available in 11 patients and were normal in 10 patients, while suspicious reflex sympathetic dystrophy was seen in one. Conclusion: Hence, it is essential to be highly aware of the entity of Lisfranc fracture-dislocation when evaluating patients who have mid foot pain, swelling, and its scintigraphic pattern. Because bone scintigraphy is, a useful modality in diagnosing Lisfranc fracture we recommend that it should be more utilized when X-ray is not diagnostic.

Prosthesis infection: diagnosis after total joint arthroplasty with three-phase bone scintigraphy.

This study investigated the diagnostic validity of Three-phase bone scintigraphy (TPBS) for diagnosing prosthetic joint infection (PJI) in cases of suspected infected total joint arthroplasty. We performed a systematic search using MEDLINE, EMBASE, and OVID databases to conduct pertinent data published between January 1990 and December 2013. Meta-analysis was used to pool sensitivity, specificity, diagnostic odds ratios (DORs), positive likelihood ratios (PLR), negative likelihood ratios (NLR), the area under the receiver-operating characteristic curve (AUC), and post-test probability. Heterogeneity and publication bias were assessed, and subgroup and meta-regression analyses were conducted. Twenty articles including a total of 704 patients were considered for analysis. The pooled sensitivity and specificity for using TPBS to detect PJI was 0.83 [95% confidence interval (CI) 0.72-0.90] and 0.73 (95% CI 0.65-0.80), respectively. The AUC, PLR, NLR, and DOR were 0.85 (95% CI 0.81-0.87), 3.1 (95% CI 2.4-4.1), 0.23 (95% CI 0.14-0.38), and 14 (95% CI 7-26), respectively. Low clinical scenario-negative post-test probabilities were 7%, and high clinical scenario-positive post-test probabilities were 90%. Subgroup analyses indicated that the sensitivity and specificity of TPBS for detecting infected arthroplasty of the hip (0.81 and 0.78, respectively) were significantly higher than those of the knee (0.75 and 0.55, respectively; p<0.05). There was no significant evidence of publication bias (p=0.34). TPBS has reasonable diagnostic value for detecting PJI and could be performed as a screening test or part of preoperative tests and analysed in conjunction with other findings at the time of suspected PJI, especially in those infections affecting the hip.

99mTc-Methylene diphosphonate SPECT/CT as the one-stop imaging modality for the diagnosis of osteoid osteoma

The aim of this study was to evaluate the utility of Tc-methylene diphosphonate (Tc-MDP) single-photon emission tomography (SPECT)/computed tomography (CT) for the diagnosis of osteoid osteoma and compare the same with three-phase planar bone scintigraphy (BS) and CT alone. Data of 31 patients (age: 20.6±13.2 years; male: 80.6%) who had undergone Tc-MDP BS with SPECT/CT for clinically and/or radiographically suspected osteoid osteoma were retrospectively evaluated. Planar BS images were analyzed by an experienced nuclear medicine physician. CT images were evaluated by an experienced radiologist. SPECT/CT images were evaluated by the nuclear medicine physician and radiologist in consensus. On the basis of the diagnostic confidence the interpreters used a scoring scale of 1-3, in which 1 is negative for osteoid osteoma, 2 is equivocal, and 3 is positive for osteoid osteoma. For the calculation of sensitivity, specificity, and predictive values for planar BS, CT, and SPECT/CT an interpretive score of 2 or higher was taken as positive for osteoid osteoma. Receiver operating characteristic curve analysis was performed and the area under the curve was calculated and compared. Histopathology and microbiology/clinical imaging follow-up was used as the reference standard. There were nine equivocal lesions on planar BS and five equivocal lesions on CT, but none on SPECT/CT. The sensitivity, specificity, and accuracy of SPECT/CT were all 100%; those of CT were 77.8, 92.3, and 83.8% and those of planar BS were 100, 38.4, and 74.1%, respectively. On comparison, the area under the curve of SPECT/CT was significantly larger than that of planar BS (1.00 vs. 0.761; P=0.005) and CT (1.00 vs. 0.872; P=0.044). However, no significant difference was seen between planar BS and CT (0.761 vs. 0.872; P=0.236). Tc-MDP SPECT/CT shows excellent diagnostic accuracy for osteoid osteoma and can be used as a one-stop imaging modality for the same. It is superior to planar BS and CT alone for the diagnosis of suspected osteoid osteoma.

Assessing diabetic foot osteomyelitis remission with white blood cell SPECT/CT imaging

Diabetic foot osteomyelitis is an important risk factor of lower limb amputation. Antibiotic therapy is often effective in preventing surgery. However, the duration of antibiotic therapy is difficult to define in the absence of a marker to diagnose osteomyelitis remission at the end of the treatment. In this study, we assessed the diagnostic performance of white blood cell SPECT/CT imaging for evaluating osteomyelitis remission. Twenty-nine out of 42 episodes of diabetic foot osteomyelitis seen between December 2009 and April 2012 had radiographs, a three-phase bone scintigraphy and a white blood cell SPECT/CT at the end of antibiotic therapy. They were treated with antibiotics alone and considered in clinical remission. White blood cell SPECT/CT results were considered positive when abnormal uptake in the osteomyelitis location was identified. Osteomyelitis remission was defined by the absence of an osteomyelitis relapse after 12 months' follow-up. A negative white blood cell SPECT/CT was seen for 22 episodes of osteomyelitis. All of them were in remission. A positive white blood cell SPECT/CT was observed for seven episodes. A relapse occurred in five episodes (71.5%) after a median duration of 4 months (2-7 months). Sensitivity, specificity, positive predictive value and predictive negative value in predicting osteomyelitis relapse after the discontinuation of antibiotic treatment were, respectively, for radiographs 80%, 33%, 20% and 89%; for three-phase bone scintigraphy 100%, 12.5%, 15.5% and 100%; and for the white blood cell SPECT/CT 100%, 91.5%, 71.5% and 100%. Negative uptake on white blood cell SPECT/CT is a good marker for diagnosis of diabetic foot osteomyelitis remission and might be very useful in guiding antibiotic therapy.

Orbital compression syndrome complicated by epidural hematoma and wide cephalohematoma in a patient with sickle cell disease

Orbital wall infarctions resulting in orbital and epidural hematomas are rare manifestations of sickle cell disease (SCD). We report orbital compression syndrome associated with an epidural hematoma and wide cephalohematoma in a 15-year-old boy with SCD. An infarcted orbital bone was observed on magnetic resonance imaging and three-phase bone scintigraphy with Technetium-99m methylene diphosphonate. The patient recovered completely without surgical intervention at the end of the fourth week. Prompt diagnosis and proper management are critical for complete recovery.

Aktuelles zur Therapie des komplex-regionalen Schmerzsyndroms

Complex regional pain syndrome (CRPS) constitutes an enigmatic post-traumatic pain disorder. The paper provides state of the art knowledge about CRPS. The typical constellation of symptoms of CRPS includes pain, sensory disturbances, motor symptoms, disturbances of the autonomic control of the limbs and trophic changes. These symptoms generalize distally and go beyond single nerve innervation territories. Diagnosis is made based on clinical findings. Three-phase bone scintigraphy may be the best supporting technical investigation. Symptoms typically change during the course of CRPS. In the acute stage inflammatory symptoms prevail and during chronic stages the most expressed findings are related to central neuroplasticity. These findings include hyperalgesia, sensory loss, CRPS movement disorder, body perception disturbances and autonomic symptoms. Medical treatment with anti-inflammatory agents (steroids) or bisphosphonates is most effective in the early stages and DMSO cream might also be beneficial. Administration of i.v. ketamine has been proven effective against CRPS pain and physical therapy with behavioral components, such as pain exposure helps to overcome central reorganization and functional impairment. Psychotherapy should be offered if there are significant comorbidities. All other forms of treatment are more or less empirical. Invasive treatment should be restricted to selected cases and should only be offered in specialized centers. If these recommendations are followed the prognosis for CRPS is not as poor as commonly assumed. Whether this means a return to the previous quality of life is unclear and often depends on very personal factors.

Bone scintigraphy in acute myeloid leukemia patient with fungal vertebral osteomyelitis

Abstract The result of the magnetic resonance imaging (MRI) study was reported as “metastasis of primary disease on L2-L3 vertebrae” in a 63-year-old male patient, who developed a back pain after receiving four courses of treatment for AML. The patient, who did not respond to pain medication, was sent to nuclear medicine department for a bone scintigraphy. Diffuse increased osteoblastic activity was reported on L2-L3 vertebrae with a suspicion about infection or fracture, together with a focal osteoblastic activity involvement in the right sacroiliac joint in the bone scintigraphy which was made with Tc99m-MDP. In the mean time, the patient complained about progressive loss of strength on bilateral lower extremities and numbness in legs. Repeated MRI was reported as “irregularities in L2-L3 vertebral disc region concordant with infection, prominent thecal pressure, loss of height in L2-L3 vertebrae associated with osteomyelitis and a mass concordant with paravertebral abscess and granulation tissue”. The patient was operated and necrotic tissue was removed by curettage, relieving the compression on L2-L3 and on the disc distance. In culture examination of the sample “candida albicans” was isolated. Antifungal treatment with Amphotericin B was started. Patient's pain was reduced and MRI findings showed some regression in abscess following the treatment. There was improvement in neurological examination. However, relapse in AML was observed in bone marrow aspiration, performed during follow-up and chemotherapy was started again. On the second day of chemotherapy high fever started and cellulitis developed on the right leg. The patient received hemodialysis treatment due to increase in BUN and creatinine levels. Pulmonary edema and associated respiratory insufficiency was developed and the patient died. Fungal infections are one of the most important clinical problems in leukemia patients. However, vertebral osteomyelitis secondary to fungal infection is relatively a rare condition and delay in diagnosis and treatment may led to serious neurological problems. Suspection of a probable fungal infection by clinicians seems vital in such cases. Bone scintigraphy has no place in routine evaluation of leukemia patients. However, we consider that bone scintigraphy should be kept in mind in the first stage of evaluation of such cases, together with other radiological examination, we think that evaluation with consideration of three-phase bone scintigraphy would be beneficial. Keywords: Candida, acute myeloid leukemia, bone scintigraphy, vertebrae osteomyelitis Ozet Akut miyeloid losemi (AML) nedeni ile 4 kur tedavi aldiktan sonra, bel agrisi gelisen 63 yasindaki erkek hastada yapilan MR incelemesi raporu “L2-L3 vertebrada primer hastaligin metastazi” idi. Agri medikasyonlarina yanit alinamayan hasta, nukleer tip bolumune kemik sintigrafisi icin gonderildi. Tc-99m MDP ile yapilan kemik sintigrafisinde, enfeksiyon veya kirik suphesi uyandiran, L2-L3 vertebralarda diffuz osteoblastik aktivite artislari bununla birlikte, sag sakroiliak eklemde fokal, osteoblastik aktivite tutulumu izlendi. Bu sirada hastada bilateral progresif alt extremitelerde guc kaybi ve bacaklarda uyusma sikayetleri gelisti. Tekrarlanan MR “L2-L3 vertebra disk mesafesinde enfeksiyon ile uyumlu gorunum, belirgin tekal basi, L2-L3 vertebralarda osteomyelite bagli yukseklik kaybi, paravertebral abse ve granulasyon dokusu ile uyumlu kitle gorunumu” olarak rapor edildi. Hasta operasyona alindi ve L2-L3 dekompresyon ve disk mesafesinde kuretaj yapilarak nekrotik doku temizlendi. Gonderilen numunenin kultur incelemesinde “Candida albicans” uredi. Amphotericin B ile antifungal tedavi baslandi. Tedaviyi takiben hastanin agrilarinda azalma oldu ve MRI bulgulari absede gerileme gosterdi. Norolojik muayenede duzelme vardi. Ancak takipleri sirasinda yapilan kemik iligi aspirasyonunda, AML’nin nuks ettigi saptandi ve yeniden kemoterapiye baslandi. Kemoterapinin 2.gununde yuksek ates, sag bacakta selulit gelisti. BUN ve kreatinin duzeylerinin yukselmesi nedeniyle hasta diyalize alindi. Akciger odemine bagli solunum yetmezligi gelisti ve hasta kaybedildi. Fungal enfeksiyonlar, losemili hastalarda en onemli klinik sorundur. Bununla birlikte fungal enfeksiyonlara sekonder gelisen vertebral osteomyelit nadir bir durumdur ve tani ve tedavideki gecikme ciddi norolojik sorunlara neden olabilir. Bu tur vakalarda klinisyenler tarafindan fungal enfeksiyondan suphelenmesi hayati onem tasir. Losemilerde kemik sintigrafisinin rutinde yeri yoktur. Bununla birlikte, bu tur vakalarin degerlendirilmesinde, kemik sintigrafisi diger radyolojik tetkikler ile birlikte ilk asamada akilda tutulmalidir ki biz uc fazli kemik sintigrafisi ile degerlendirme yapilmasinin yararli olacagini dusunmekteyiz. Anahtar sozcukler: Candida, Akut myeloid losemi, kemik sintigrafi, vertebra osteomyelit

A Low Recurrence Rate is Possible With a Combination of Surgery and Radiosynovectomy for Diffuse Pigmented Villonodular Synovitis of the Knee

Diffuse pigmented villonodular synovitis (DPVNS) is an uncommon proliferative disease. After only surgery, recurrence rates are high. This study presents the efficacy of combined surgical and adjuvant radiosynovectomy (RS) in the treatment of DPVNS. Between September 2006 and September 2012, 15 knee joints of 15 patients (10 female and 5 male) with histopathological DPVNS diagnosis with mean age 27 ± 12 years underwent surgery. At mean 14.4 ± 18 weeks postoperatively, RS was applied using 5 mCi (90)Y citrate colloid. Three-phase bone scintigraphy and contrast-enhanced MRI were used to evaluate residual and recurrent tumorous tissues in the joint. Mean follow-up was 48 ± 22 months. Blood flow and blood pool images showed that 2 patients had marked, 4 had moderate, 6 had mild, and 3 had no uptake. Late static images showed 5 had marked, 10 had moderate (99m)Tc-HDP uptake in the related joint. MRI examination indicated that there was no progression in any of the patients. The disease was determined to be stable in 2, regressed in 9, and totally cured in 4 cases. Bremsstrahlung imaging indicated an even distribution of radionuclide in all the knee joints. There was no evidence of leakage of radioactivity in the total body scans. There was significant improvement in Lysholm knee scores after treatment. Adjuvant yttrium-90 radiosynovectomy after surgical excision in the treatment of DPVNS is a reliable and efficient treatment method with successful clinical results. RS treatment can be considered for cases with DPVNS.

Scintigraphy in postoperative follow-up of osteosynthesis of the femur with a bridge plate associated with an intramedullary pin in rabbits

The objective of this work was to monitor the consolidation of the femur after osteosynthesis with a bridge plate associated with the intramedullary pin using scintigraphy. We used seven New Zealand breed male rabbits, at 4 months of age, with a mean weight of 3.5 kg. We performed a three-phase bone scintigraphy with technetium-labeled methylene diphosphonate (99mTc-MDP) before and after surgery, and 20, 50 and 90 days postoperatively. The activity index (AI) was calculated by dividing the average number of uptake counts in the region of the osteotomy by the average number of counts in the corresponding region in the contralateral limb. Radiography was performed before surgery, after surgery, and 15, 30, 45, 60 and 90 days postoperatively. We found a direct relationship between the activity index and progress of bone scintigraphy in the evaluation sequence over the period of observation. Scintigraphy allows monitoring of bone metabolism and measurement of vascularization and/or bone or tissue perfusion. The images obtained in the blood pool and static phases are the most appropriate for assessing bone metabolism in the context of this study. The bridge plate associated with the intramedullary pin promotes osteosynthesis with sufficient stability to allow bone consolidation.

Role of three-phase bone scintigraphy in paediatric osteoid osteoma eligible for radiofrequency ablation

The objective of the study was to underline the importance of three-phase bone scintigraphy at the time of diagnosis in children with suspected osteoid osteoma (OO) who are eligible for radiofrequency ablation. Fifty-three patients (13 girls; mean age 7.2 years, 20% younger than 10 years of age) who underwent bone scintigraphy for suspected OO between 2005 and 2010 were included in the study, of whom 46 underwent a radiography at diagnosis. Computed tomography-guided biopsy was performed in all patients after bone scintigraphy, and radiofrequency ablation was performed following biopsy in patients with OO; ablation efficacy was confirmed by MRI at 1, 3, 12 and 18 months. The radiographic results were negative in 27/46 patients and was unclear in 19. Bone scintigraphy showed lesions in 53/53 patients, of whom 51 patients had a typical pattern of osteoma and nine patients required an additional scan with a pinhole collimator. Histological examination showed OO in 51/53 patients (3/51 intramedullary), Ewing's sarcoma in 1/53 patients, and chronic osteomyelitis in 1/53 patients. Any child with recurrent nocturnal pain and/or limb swelling should undergo radiography of the involved skeletal segment, which is the first-choice diagnostic method in the clinical suspicion of OO. In the event of ambiguous or negative radiographic results, bone scintigraphy is needed to exclude other pathologic conditions and to confirm the diagnosis. In children with recurrent but not well-localized bone pain in which OO is strongly suspected for signs and symptoms, a bone scan can help detect the lesion. The diagnostic accuracy of the bone scan, particularly for the appendicular skeleton, can be improved by pinhole collimator acquisition.

Usefulness of asymmetry score on quantitative three-phase bone scintigraphy in the evaluation of complex regional pain syndrome

Introduction:Complex regional pain syndrome (CRPS) is primarily a clinical diagnosis. Diagnostic imaging in CRPS can be used, especially to exclude other disorders. The sensitivity and specificity of three phase bone scintigraphy (TPBS) for the diagnosis of CRPS is variable throughout the literature.Aim:To establish a simple and effective quantitative approach to help in the diagnosis of CRPS by TPBS.Materials and Methods:TPBS done in patients (n = 68) with suspected CRPS was analyzed retrospectively. They were classified into bone scan positive group (BSP), bone scan negative group (BSN) and non-CRPS group based on diffusely increased periarticular uptake, symmetrical uptake, and focal uptake respectively. Asymmetry score (AS) was also measured between the affected and unaffected side.Results:16 patients showed focal uptake, 37 were in BSP group with mean AS score of 1.57 ± 0.5 and 15 were in BSN group with mean AS score of 1.01 ± 0.05. The mean AS was significantly different (P < 0.0001). AS of 1.06 had sensitivity and specificity of 96.43% and 100% respectively (P = 0.0001). There was a trend of negative correlation between the AS and the duration, r = −0.21; however, it was not statistically significant (P = 0.28).Conclusion:TPBS should be considered in the evaluation of CRPS to rule out patients who have focal involvement, not diagnostic of CRPS (~24% in this study). Quantitative AS of 1.06 can be included to support visual interpretation in the delayed phase.

Skull base osteomyelitis in otitis externa: The utility of triphasic and single photon emission computed tomography/computed tomography bone scintigraphy

Background:Skull base osteomyelitis (SBO) refers to infection that has spread beyond the external auditory canal to the base of the skull in advanced stages of otitis externa. Clinically, it may be difficult to differentiate SBO from severe otitis externa without bony involvement. This study was performed to determine the role of three phase bone scintigraphy (TPBS) and single photon emission tomography/computed tomography (SPECT/CT) in detecting SBO.Materials and Methods:We retrospectively analyzed records of 20 patients (14 M, 6 F) with otitis externa and suspected SBO. TPBS and SPECT/CT of the skull were performed. Findings were correlated with clinical, laboratory and diagnostic CT scan findings.Results:All patients were diabetic with elevated erythrocyte sedimentation rate. A total of 18 patients had bilateral and two unilateral symptoms. Cranial nerves were involved in eight patients and microbiological culture of ear discharge fluid positive in seven. Early images showed increased temporal vascularity in nine patients and increased soft-tissue uptake in 10, while delayed images showed increased bone uptake in 19/20 patients. Localized abnormal tracer uptake was shown by SPECT/CT in the mastoid temporal (15), petrous (11), sphenoid (3) and zygomatic (1) and showed destructive changes in five. Thus, TPBS was found positive for SBO in 10/20 patients and changed the management in four.Conclusion:Our study suggests that TPBS with SPECT/CT is a useful non-invasive investigation for detection of SBO in otitis externa.

Periprosthetic Joint Infections

Implantation of joint prostheses is becoming increasingly common, especially for the hip and knee. Infection is considered to be the most devastating of prosthesis-related complications, leading to prolonged hospitalization, repeated surgical intervention, and even definitive loss of the implant. The main risk factors to periprosthetic joint infections (PJIs) are advanced age, malnutrition, obesity, diabetes mellitus, HIV infection at an advanced stage, presence of distant infectious foci, and antecedents of arthroscopy or infection in previous arthroplasty. Joint prostheses can become infected through three different routes: direct implantation, hematogenic infection, and reactivation of latent infection. Gram-positive bacteria predominate in cases of PJI, mainly Staphylococcus aureus and Staphylococcus epidermidis. PJIs present characteristic signs that can be divided into acute and chronic manifestations. The main imaging method used in diagnosing joint prosthesis infections is X-ray. Computed tomography (CT) scan may assist in distinguishing between septic and aseptic loosening. Three-phase bone scintigraphy using technetium has high sensitivity, but low specificity. Positron emission tomography using fluorodeoxyglucose (FDG-PET) presents very divergent results in the literature. Definitive diagnosis of infection should be made by isolating the microorganism through cultures on material obtained from joint fluid puncturing, surgical wound secretions, surgical debridement procedures, or sonication fluid. Success in treating PJI depends on extensive surgical debridement and adequate and effective antibiotic therapy. Treatment in two stages using a spacer is recommended for most chronic infections in arthroplasty cases. Treatment in a single procedure is appropriate in carefully selected cases.

Atypical Osteomyelitis Caused byMycobacterium chelonae—A Multimodal Imaging Approach

We present an unusual case of a biopsy-proven Mycobacterium chelonae infection (MCI) of skin and soft tissue, which led to osteomyelitis in a 55-year-old Caucasian male. We provide clinical data and discussion about MCI and its diagnostic workup and demonstrate comprehensive imaging findings, including clinical pictures, radiographs, three-phase bone scintigraphy, and combined SPECT/CT findings of this entity, which have not yet been presented in the medical literature.

The added value of (99)Tcm-MDP SPECT/CT combined with three-phase bone scintigraphy for differential diagnosis in patients with suspected bone tumor

Objective To investigate the added value of SPECT/CT combined with three-phase bone scintigraphy for differential diagnosis in patients with suspected bone tumor compared with 99Tcm-MDP three-phase bone scintigraphy.Methods Forty-five patients with mean age (44.1 ±21.2) years who were suspected to have bone tumors,underwent 99Tcm-MDP three-phase bone scintigraphy and SPECT/CT between July 2008 and September 2011.They were retrospectively reviewed.All patients had pathological diagnosis based on surgical resection or lesion biopsy.The three-phase bone scintigraphy images were analyzed,and combined SPECT/CT images were then analyzed by two experienced nuclear medicine physicians.The third nuclear medicine physician would be consulted if there was disagreement between these two investigators.Each lesion was diagnosed as either malignant or benign.Compared with the pathology diagnosis,the diagnostic ability of three-phase bone scintigraphy images and SPECT/CT combined with threephase bone scintigraphy were evaluated.The diagnostic accuracy of three-phase bone scintigraphy images and SPECT/CT combined with three-phase bone scintigraphy were calculated,and x2 test was used to compare the difference between them.Results Among these 45 lesions,29 were malignant and 16 benign.Using three-phase bone scintigraphy and SPECT/CT combined with three-phase bone scintigraphy for the differential diagnosis of bone lesions,the sensitivity,specificity,positive predictive value and negative predictive value were 96.6％ (28/29) vs 100％ (29/29),37.5％ (6/16) vs 81.2％ (13/16),73.7％ (28/38) vs 90.6％ (29/32),and 6/7 vs 100％ (13/13),respectively.The diagnostic accuracy of the three-phase bone scintigraphy was 75.6％ (34/45),and up to 93.3％ (42/45) for the combined examination (x2 =4.145,P ＜0.05).Conclusions Compared with three-phase bone scintigraphy alone,the diagnostic accuracy of SPECT/CT combined with three-phase bone scintigraphy is significantly improved.The combination might provide added value over three-phase bone scintigraphy for differential diagnosis in patients with suspected bone tumor. Key words: Bone neoplasms; Radionuclide imaging; Tomography,emission-computed,single-photon; Tomography,X-ray computed; MDP

Modern management of patients with frostbite

Background: Frostbite is a local cold injury that may lead to loss of tissue, and result in disability. It is normally a consequence of prolonged exposure of unprotected regions to subzero ambient temperatures, which causes impairment of the microcirculation. In Slovenia, the main risk group for frostbite injury are mountain climbers. Frostbite is classified as either a superficialreversible injury, or an irreversible deep tissue injury. Superficial frostbite is managed in out-patient clinics, whereas hospital treatment is required for deep frostbite. The success of frostbite management depends a great deal on the field first aid and emergency medical treatment, as well as on the subsequent hospital treatment. The present study reports of the success of a protocol for hospital treatment of frostbite (Planica Protocol), comprising the early diagnosis with three-phase bone scintigraphy (TS), administration of appropriate medications, particularly iloprost, and initiation of hyperbaric oxygen treatment (HBOT). Patients and methods: A total of 27 mountain climbers presented with frostbite injury between 2000 and 2010. Of these, 16 suffered superficial injuries and were treated as outpatients. The remaining 11 mountaineers (2 females, and 9 males) suffered deep frostbite and were hospitalised. Frostbite injury was sustained at different altitudes (range: 2000 to 8848 meters above sea level) in the toes (n = 9; 82 %) and fingers (n = 2; 18 %). Some climbers (n = 9; 82 %) received field first aid, and some (n = 9; 82 %) also emergency medical treatment in the field. On admission to hospital, patients received the following treatpatient clinics, whereas hospital treatment is required for deep frostbite. The success of frostbite management depends a great deal on the field first aid and emergency medical treatment, as well as on the subsequent hospital treatment. The present study reports of the success of a protocol for hospital treatment of frostbite (Planica Protocol), comprising the early diagnosis with three-phase bone scintigraphy (TS), administration of appropriate medications, particularly iloprost, and initiation of hyperbaric oxygen treatment (HBOT). Patients and methods: A total of 27 mountain climbers presented with frostbite injury between 2000 and 2010. Of these, 16 suffered superficial injuries and were treated as outpatients. The remaining 11 mountaineers (2 females, and 9 males) suffered deep frostbite and were hospitalised. Frostbite injury was sustained at different altitudes (range: 2000 to 8848 meters above sea level) in the toes (n = 9; 82 %) and fingers (n = 2; 18 %). Some climbers (n = 9; 82 %) received field first aid, and some (n = 9; 82 %) also emergency medical treatment in the field. On admission to hospital, patients received the following treatment: early diagnosis with TS (n = 7; 64 %); pharmaceutcial interventions, including acetylsalicylic acid, low-molecular weight heparin, pentoxifylline, antibiotics, iloprost (n = 8; 64 %); and HBOT (n = 8; 73 %). Results: Of the 11 climbers with deep frostbite, tissue loss and amputation was avoided in 6 (55 %). Necrectomy (full amputation) was performed in 5 climbers (45 %): full-length digit amputation (n = 2), and part-length (one or two phalanges) amputations (n = 3). Amputation of the toes was required in both female climbers. Conclusions: Timely field first aid and emergency medical treatment is of paramount importance for a good outcome of frostbite injury. Early diagnostics using three-phase bone scintigraphy (TS) can assess the extent of tissue damage before final clinical manifestation of frostbite is fully developed. The Planica Protocol for the treatment of frostbite injury, comprising early diagnostics (TS), proper medication (acetylsalicylic acid, low-molecular weight heparin, pentoxifylline, antibiotics, iloprost), and HBOT appears to provide a beneficial outcome of deep frostbite injury.

Intact versus Fragmented 99mTc-Monoclonal Antibody Imaging of Infection in Patients with Septically Loosened Total Knee Arthroplasty

This prospective study compared the diagnostic accuracy of imaging using an intact murine antigranulocyte antibody 99mTc-besilesomab, and a murine antibody Fab fragment 99mTc-sulesomab, in patients with suspected septically loosened total knee arthroplasty. Images from 20 patients who underwent threephase bone scintigraphy followed by imaging using 99mTc-besilesomab (n=10) or 99mTc-sulesomab (n=10) were evaluated and compared. Final diagnosis was determined by microbiological evaluation of aspirated synovial fluid, intraoperative samples through the clinical course, or by long-term follow-up. Prosthesis infection was shown in 18 patients. At 4 and 24 h after intravenous injection, absolute uptake of 99mTc-besilesomab was significantly higher than 99mTc-sulesomab in infected knee joints. Infected-to-healthy knee activity ratios were similar at 4 and 24 h for 99mTc-besilesomab and 99mTc-sulesomab. Both 99mTc-besilesomab and 99mTc-sulesomab had similar diagnostic accuracy for the detection of septic arthroplasty. If repeated use of immunoscintigraphy is needed for follow-up, 99mTc-sulesomab should be preferred over 99mTc-besilesomab since it is known to be well tolerated and without side effects or incompatibility reactions.