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Kompel A, Guermazi A. Imaging of MSK infections in the ER. Skeletal Radiol 2023:10.1007/s00256-023-04554-7. [PMID: 38147081 DOI: 10.1007/s00256-023-04554-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 12/10/2023] [Accepted: 12/17/2023] [Indexed: 12/27/2023]
Abstract
Musculoskeletal infections in the ER are not an uncommon presentation. The clinical context is critical in determining the suspicion for infection and degree of tissue involvement which can involve all layers from the skin to bones. The location, extent, and severity of clinically suspected infection directly relate to the type of imaging performed. Uncomplicated cellulitis typically does not require any imaging. Localized and superficial infections can mostly be evaluated with ultrasound. If there is a diffuse site (an entire extremity) or suspected deeper involvement (muscle/deep fascia), then CT is accurate in diagnosing, widely available, and performed quickly. With potential osseous involvement, MRI is the gold standard for diagnosing acute osteomyelitis; however, it has the drawbacks of longer scan times, artifacts including patient motion, and limited availability.
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Affiliation(s)
- Andrew Kompel
- Boston University School of Medicine, Boston, MA, USA.
| | - Ali Guermazi
- Boston University School of Medicine, Boston, MA, USA
- Boston VA Healthcare System, West Roxbury, MA, USA
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2
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Jardon M, Alaia EF. Approach to imaging modalities in the setting of suspected infection. Skeletal Radiol 2023:10.1007/s00256-023-04478-2. [PMID: 37857751 DOI: 10.1007/s00256-023-04478-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/03/2023] [Accepted: 10/04/2023] [Indexed: 10/21/2023]
Abstract
Imaging plays an important role in the workup of musculoskeletal infection, in conjunction with clinical history and physical exam. There are multiple imaging modalities that can be of clinical utility in the setting of suspected infection, each with their own benefits and limitations. Radiography is a low-cost, accessible modality providing a broad osseous overview, but can be insensitive for early osteomyelitis. Ultrasound plays a more limited role in the workup of musculoskeletal infection, but can be useful in the pediatric population or for real-time guidance for joint and soft tissue aspirations. Computed tomography (CT) plays an important role in the timely and accurate diagnosis of critically ill patients in the emergency setting. Its superior soft tissue characterization allows for diagnosis of abscesses, and it can help confirm the clinical diagnosis of necrotizing fasciitis when soft tissue gas is present. Magnetic resonance imaging (MRI) is often the modality of choice in the diagnosis of infection, as its superior contrast resolution allows for clear delineation of the presence and extent of both soft tissue infection and osteomyelitis. Additionally, the use of intravenous contrast and advanced imaging sequences such as diffusion weighted imaging (DWI) further increases the diagnostic utility of MRI in the assessment for infection. Familiarity with the diagnostic utility of each imaging modality will allow the radiologist to appropriately guide imaging workup in the setting of clinically suspected infection.
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Affiliation(s)
- Meghan Jardon
- Department of Radiology, NYU Langone Medical Center, New York, NY, USA.
| | - Erin F Alaia
- Department of Radiology, NYU Langone Medical Center, New York, NY, USA
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Wang Y, Sun Z, Liang X, Shen C. Inguinal draining-lymph node in 18F-FDG PET/CT images could be a new indicator for the diagnosis of fracture-related infection in the lower extremities. Front Immunol 2023; 14:1206682. [PMID: 37868952 PMCID: PMC10585159 DOI: 10.3389/fimmu.2023.1206682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 08/28/2023] [Indexed: 10/24/2023] Open
Abstract
Purpose The imaging diagnosis of fracture-related infection is often challenging. The aim of this study was to evaluate the value of 18F-FDG PET/CT for the diagnosis of fracture-related infection (FRI) with internal fixation after orthopedic surgery in lower extremities. Methods A total of 254 consecutive patients who underwent 18F-FDG PET/CT scans with suspected FRI with internal fixation in lower extremities were retrospectively investigated 18F-FDG PET/CT images were semiquantitatively evaluated with multiple metabolic parameters. Additionally, morphological information of the inguinal draining lymph nodes (DLN) with the highest SUV value was also collected and analyzed. Results Patients were divided into two groups according to final diagnosis: the infected (N=197) and the non-infected group (N=57). The differences in the inguinal DLN-related parameters, including the long diameter, short diameter, maximum cross-sectional area, maximum standardized uptake value (SUVmax), metabolic volume (MV) 60%, MV70%, MV80%, total lesional glycolysis (TLG) 60%, TLG70%, TLG80%, and the infection suspected area related parameters, including SUVmax, MV25%, MV30%, MV35%, MV40%, MV50%, and TLG70%, between the two groups were statistically significant. We then compared the highest area under the curves (AUCs) among the morphological parameters of DLN, metabolic parameters of DLN, and metabolic parameters of the suspected infection area. The result demonstrated that SUVmax of the inguinal DLN showed the best diagnostic performance with an AUC of 0.939 (P<0.05). Conclusion Semiquantitative analysis (especially SUVmax) of the inguinal DLN in 18F-FDG PET/CT images could be a promising method for the diagnosis of suspected FRI with internal fixation after orthopedic surgery in lower extremities.
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Affiliation(s)
- Yanbing Wang
- Department of Nuclear Medicine, Rizhao People’s Hospital, Rizhao, Shandong, China
- Department of Nuclear Medicine, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhenkui Sun
- Department of Nuclear Medicine, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Bone Nonunion and Bone Infection Multidisciplinary Team (MDT), Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiao Liang
- Department of Radiology, Rizhao People’s Hospital, Rizhao, Shandong, China
| | - Chentian Shen
- Department of Nuclear Medicine, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Bone Nonunion and Bone Infection Multidisciplinary Team (MDT), Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Rusche T, Vosshenrich J, Winkel DJ, Donners R, Segeroth M, Bach M, Merkle EM, Breit HC. More Space, Less Noise-New-generation Low-Field Magnetic Resonance Imaging Systems Can Improve Patient Comfort: A Prospective 0.55T-1.5T-Scanner Comparison. J Clin Med 2022; 11:jcm11226705. [PMID: 36431182 PMCID: PMC9692643 DOI: 10.3390/jcm11226705] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/09/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES The objectives of this study were to assess patient comfort when imaged on a newly introduced 0.55T low-field magnetic resonance (MR) scanner system with a wider bore opening compared to a conventional 1.5T MR scanner system. MATERIALS AND METHODS In this prospective study, fifty patients (mean age: 66.2 ± 17.0 years, 22 females, 28 males) underwent subsequent magnetic resonance imaging (MRI) examinations with matched imaging protocols at 0.55T (MAGNETOM FreeMax, Siemens Healthineers; Erlangen, Germany) and 1.5T (MAGNETOM Avanto Fit, Siemens Healthineers; Erlangen, Germany) on the same day. MRI performed between 05/2021 and 07/2021 was included for analysis. The 0.55T MRI system had a bore opening of 80 cm, while the bore diameter of the 1.5T scanner system was 60 cm. Four patient groups were defined by imaged body regions: (1) cranial or cervical spine MRI using a head/neck coil (n = 27), (2) lumbar or thoracic spine MRI using only the in-table spine coils (n = 10), (3) hip MRI using a large flex coil (n = 8) and (4) upper- or lower-extremity MRI using small flex coils (n = 5). Following the MRI examinations, patients evaluated (1) sense of space, (2) noise level, (3) comfort, (4) coil comfort and (5) overall examination impression on a 5-point Likert-scale (range: 1= "much worse" to 5 = "much better") using a questionnaire. Maximum noise levels of all performed imaging studies were measured in decibels (dB) by a sound level meter placed in the bore center. RESULTS Sense of space was perceived to be "better" or "much better" by 84% of patients for imaging examinations performed on the 0.55T MRI scanner system (mean score: 4.34 ± 0.75). Additionally, 84% of patients rated noise levels as "better" or "much better" when imaged on the low-field scanner system (mean score: 3.90 ± 0.61). Overall sensation during the imaging examination at 0.55T was rated as "better" or "much better" by 78% of patients (mean score: 3.96 ± 0.70). Quantitative assessment showed significantly reduced maximum noise levels for all 0.55T MRI studies, regardless of body region compared to 1.5T, i.e., brain MRI (83.8 ± 3.6 dB vs. 89.3 ± 5.4 dB; p = 0.04), spine MRI (83.7 ± 3.7 dB vs. 89.4 ± 2.6 dB; p = 0.004) and hip MRI (86.3 ± 5.0 dB vs. 89.1 ± 1.4 dB; p = 0.04). CONCLUSIONS Patients perceived 0.55T new-generation low-field MRI to be more comfortable than conventional 1.5T MRI, given its larger bore opening and reduced noise levels during image acquisition. Therefore, new concepts regarding bore design and noise level reduction of MR scanner systems may help to reduce patient anxiety and improve well-being when undergoing MR imaging.
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Crim J, Salmon S, Waranch C, Elfrink J, Layfield E, Stensby JD. Update on MRI findings of osteomyelitis of long bones in the adult population. Skeletal Radiol 2022; 51:1787-1796. [PMID: 35226132 DOI: 10.1007/s00256-022-04020-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 02/15/2022] [Accepted: 02/15/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate the usefulness of new and established MRI signs of osteomyelitis in long bones in adults. METHODS All patient records over a 9-year period with clinical or MRI suspicion for osteomyelitis were retrospectively reviewed, using strict criteria for proof of infection. Two musculoskeletal radiologists independently reviewed the MRIs of proven osteomyelitis. RESULTS Out of 45 MRIs of confirmed osteomyelitis, 2 MRIs (4%) did not show confluent low-signal intensity on T1-weighted images, but all showed confluent high-signal intensity on T2-weighted images. Central hypoenhancing regions of marrow without abscess formation were found in 15-18/35 (43-51%) cases where gadolinium was given. We often found multiple foci of marrow replacement in the same bone. The areas of marrow involvement often had an irregular contour. Penumbra sign, marrow fat globules, and sequestra were uncommon. CONCLUSION Multiple foci of bone marrow signal abnormalities, an irregular contour of marrow abnormality, and central marrow hypoenhancement without abscess are common signs of osteomyelitis of long bones in adults. Confluent low T1-signal intensity is not always present.
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Affiliation(s)
- Julia Crim
- University of Missouri at Columbia, 1 Hospital Dr, Columbia, MO, 65212, USA.
| | - Samantha Salmon
- University of Missouri at Columbia, 1 Hospital Dr, Columbia, MO, 65212, USA
| | - Christy Waranch
- University of Missouri at Columbia, 1 Hospital Dr, Columbia, MO, 65212, USA
| | - Jacob Elfrink
- University of Missouri at Columbia, 1 Hospital Dr, Columbia, MO, 65212, USA
| | | | - J Derek Stensby
- University of Missouri at Columbia, 1 Hospital Dr, Columbia, MO, 65212, USA
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Vosshenrich J, Breit HC, Bach M, Merkle EM. [Economic aspects of low-field magnetic resonance imaging : Acquisition, installation, and maintenance costs of 0.55 T systems]. Radiologe 2022; 62:400-404. [PMID: 35348808 PMCID: PMC9061693 DOI: 10.1007/s00117-022-00986-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Low-field magnetic resonance imaging (MRI) scanners offer an opportunity for cost reduction in the healthcare system. This is due to lower manufacturing costs and reduced construction requirements for installation and operation. OBJECTIVES To discuss potential cost reductions in acquisition, installation, and maintenance by using new low-field MRI systems. METHODS We provide an overview of key cost drivers and an evaluation of the potential savings of a recent generation 0.55T low-field MRI compared to conventional 1.5T and 3T MRI systems in routine clinical practice. RESULTS In terms of purchase price, the savings potential of a 0.55T MRI compared to a 1.5T MRI system is about 40-50%. The 25% lower weight of the system reduces the transportation costs incurred, and the smaller size of the unit allows for installation by a remotely controlled mobile robotic system without opening the exterior façade, if the operating site is at ground level. Together with the lack of need to install a quench pipe, this reduces the total cost of installation by up to 70%. The maintenance cost of a 0.55T MRI is approximately 45% less than that of a 1.5T unit with a comparable service contract. Further cost reductions result from the smaller room size and potentially lower energy consumption for examinations and cooling. CONCLUSION The use of lower field strength MRI systems offers enormous economic and environmental potential for both hospitals and practice operators, as well as for the healthcare system as a whole.
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Affiliation(s)
- Jan Vosshenrich
- Klinik für Radiologie und Nuklearmedizin, Universitätsspital Basel, Petersgraben 4, 4031, Basel, Schweiz
| | - Hanns-Christian Breit
- Klinik für Radiologie und Nuklearmedizin, Universitätsspital Basel, Petersgraben 4, 4031, Basel, Schweiz.
| | - Michael Bach
- Klinik für Radiologie und Nuklearmedizin, Universitätsspital Basel, Petersgraben 4, 4031, Basel, Schweiz
| | - Elmar M Merkle
- Klinik für Radiologie und Nuklearmedizin, Universitätsspital Basel, Petersgraben 4, 4031, Basel, Schweiz
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Abstract
The clinical diagnosis of musculoskeletal infections can be challenging due to non-specific signs and symptoms on presentation. These infections include infectious myositis, necrotising fasciitis, septic arthritis, septic bursitis, suppurative tenosynovitis, osteomyelitis, spondylodiscitis and periprosthetic infections. Diagnostic imaging is routinely employed as part of the investigative pathway to characterise the underlying infectious disease pattern, allowing expedited and customised patient management plans to optimise outcomes. This article provides an update on the various imaging modalities comprising of radiography, computed tomography, ultrasonography, magnetic resonance imaging and radionuclide procedures, and incorporates representative images of key findings in the different forms of musculoskeletal infections.
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Paliwal AK, Sahdev R, Deshwal A, Ram B. Role of ultrasound in the diagnosis of paediatric acute osteomyelitis. J Ultrason 2021; 21:34-40. [PMID: 33791114 PMCID: PMC8008204 DOI: 10.15557/jou.2021.0005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 01/06/2021] [Indexed: 11/22/2022] Open
Abstract
Aim The aims of our study were to evaluate cases of extremity pain or swelling in paediatric patients using USG to diagnose acute osteomyelitis, and correlate USG findings with MRI findings. Material and methods 18 paediatric patients with extremity pain or swelling were evaluated. After the clinical and laboratory work-up, imaging was done using radiographic examination, USG and MRI of the affected limb. Results 5 patients (27.8%) out of 18 were diagnosed with acute osteomyelitis based on USG findings, confirmed by MRI and surgical drainage. The mean age of the patients with acute osteomyelitis was 8.2 years. Male children were more commonly affected as compared to female. The distal metaphysis of the femur was the most common site involved (80%). The right lower limb was more commonly affected. The most frequent presentation was pain at the affected site. On USG, deep soft tissue fluid collection around the bone was present in all cases (100%). Periosteal thickening or elevation with subperiosteal fluid collection was seen in 4 cases (80%). Increased vascularity within or around the periosteum on colour Doppler was seen in 4 cases (80%). Conclusions Acute osteomyelitis is a common entity in the paediatric population, presenting with acute limb pain and swelling. Early diagnosis and management of acute osteomyelitis are essential to prevent serious complications. USG can play an important role in the early diagnosis of paediatric acute osteomyelitis, and should be incorporated into the treatment protocols followed in cases of suspected acute osteomyelitis. MRI should be reserved as problem-solving tool.
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Affiliation(s)
| | - Ravinder Sahdev
- Department of Radiology, Military Hospital Secundrabad, India
| | - Ankur Deshwal
- Department of Orthopaedics, Military Hospital Jodhpur, India
| | - Birma Ram
- Department of Radiology, Military Hospital Jodhpur, India
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9
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Abstract
The Society of Skeletal Radiology (SSR) Practice Guidelines and Technical Standards Committee identified musculoskeletal infection as a White Paper topic, and selected a Committee, tasked with developing a consensus on nomenclature for MRI of musculoskeletal infection outside the spine. The objective of the White Paper was to critically assess the literature and propose standardized terminology for imaging findings of infection on MRI, in order to improve both communication with clinical colleagues and patient care.A definition was proposed for each term; debate followed, and the committee reached consensus. Potential controversies were raised, with formulated recommendations. The committee arrived at consensus definitions for cellulitis, soft tissue abscess, and necrotizing infection, while discouraging the nonspecific term phlegmon. For bone infection, the term osteitis is not useful; the panel recommends using terms that describe the likelihood of osteomyelitis in cases where definitive signal changes are lacking. The work was presented virtually to SSR members, who had the opportunity for review and modification prior to submission for publication.
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10
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Phillips WT, Gorzell BC, Martinez RA, Salman UA, Cooper AW, Stocker DJ, Adams CC. Fewer-Angle SPECT/CT Blood Pool Imaging for Infection and Inflammation. J Nucl Med Technol 2020; 49:39-43. [PMID: 33361187 DOI: 10.2967/jnmt.120.256933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 10/22/2020] [Indexed: 11/16/2022] Open
Abstract
A new protocol for rapid SPECT/CT blood pool imaging consisting of fewer image-angle acquisitions (fewer-angle SPECT/CT, or FASpecT/CT) was evaluated for localization of focal sites of soft-tissue inflammation, infection, and osteomyelitis. Methods: Immediately after dynamic flow and standard planar blood pool imaging with 99mTc-methylene diphosphonate, FASpecT/CT was performed with a dual-head γ-camera consisting of 6 steps over 360°, 12 total images with 30° of separation between angles, and 30 s per image, requiring a total imaging time of approximately 3 min. Images were reconstructed using iterative ordered-subset expectation maximization. Before use in a patient-care setting, various FASpecT/CT acquisition protocols were modeled using a phantom to determine the minimum number of stops and the stop duration required to produce a reliable image. Results: FASpecT/CT images provided excellent 3-dimensional localization of spine osteomyelitis, soft-tissue infection of the foot, and tendonitis of the hand and foot using a 3-min image acquisition time. The FASpecT/CT acquisition protocol required 1.3-3.5 min, including camera movement time. This was a reduction of 72%-90% from the time required for the standard 60-angle, 20-s SPECT/CT acquisition. Conclusion: The ability of FASpecT/CT blood pool images to help localize focal sites of hyperemia and inflammation can increase exam sensitivity and specificity. Additionally, using a FASpecT/CT protocol decreases imaging time by up to 90%.
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Affiliation(s)
- William T Phillips
- Department of Radiology, University of Texas Health Science Center, San Antonio, Texas.,Department of Radiology, University Hospital, San Antonio, Texas; and
| | - Brandon C Gorzell
- Department of Radiology, University of Texas Health Science Center, San Antonio, Texas
| | - Robert A Martinez
- Department of Radiology, University of Texas Health Science Center, San Antonio, Texas
| | - Umber A Salman
- Department of Radiology, University Hospital, San Antonio, Texas; and
| | - Albert W Cooper
- Department of Radiology, University of Texas Health Science Center, San Antonio, Texas
| | - Derek J Stocker
- Department of Radiology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Chad C Adams
- Department of Radiology, Walter Reed National Military Medical Center, Bethesda, Maryland
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Cohen LL, Shore BJ, Williams KA, Hedequist DJ, Hresko MT, Emans JB, Karlin LI, Snyder BD, Glotzbecker MP. Diagnosing and treating native spinal and pelvic osteomyelitis in adolescents. Spine Deform 2020; 8:1001-1008. [PMID: 32306283 DOI: 10.1007/s43390-020-00110-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 03/25/2020] [Indexed: 10/24/2022]
Abstract
STUDY DESIGN Retrospective case series. OBJECTIVES To describe how pediatric patients with spinal and pelvic osteomyelitis are diagnosed and treated and assess the diagnostic value of magnetic resonance imaging (MRI), needle aspiration biopsy (NAB), and blood cultures in this population. Spinal and pelvic osteomyelitis de novo are uncommon in children and minimal literature exists on the subject. Research has shown that NAB and blood cultures have variable diagnostic yield in adult native osteomyelitis. At our institution, there is no standard protocol for diagnosing and treating pediatric spinal and pelvic osteomyelitis de novo. METHODS All diagnoses of spinal and pelvic osteomyelitis at a pediatric tertiary care center from 2003 to 2017 were reviewed. Patients aged 0-21 at diagnosis were included. Patients with osteomyelitis resulting from prior spinal operations, wounds, or infections and those with chronic recurrent multifocal osteomyelitis were eliminated. All eligible patients' diagnoses were confirmed by MRI. RESULTS 29 patients (18 men, 11 women) met the inclusion criteria. The median age at diagnosis was 11 years old (range 1-18). More than half of all cases (17/29, 59%) affected the lumbar spine. The most common symptoms were back pain (20/29, 69%), fever (18/29, 62%), hip pain (11/29, 38%), and leg pain (8/29, 28%). The majority of NABs and blood cultures performed were negative, but of the positive tests Staphylococcus aureus was the most prevalent bacteria. 86% (25/29) had an MRI before a diagnosis was made and 72% (13/18) had an NAB performed post-diagnosis. CONCLUSIONS MRI is a popular and helpful tool in diagnosing spinal osteomyelitis de novo. NAB cultures are often negative but can be useful in determining antibiotic treatment. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Lara L Cohen
- Department of Orthopedic Surgery, Boston Children's Hospital, Hunnewell 2, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Benjamin J Shore
- Department of Orthopedic Surgery, Boston Children's Hospital, Hunnewell 2, 300 Longwood Avenue, Boston, MA, 02115, USA.,Harvard Medical School, Boston, MA, USA
| | - Kathryn A Williams
- Department of Orthopedic Surgery, Boston Children's Hospital, Hunnewell 2, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Daniel J Hedequist
- Department of Orthopedic Surgery, Boston Children's Hospital, Hunnewell 2, 300 Longwood Avenue, Boston, MA, 02115, USA.,Harvard Medical School, Boston, MA, USA
| | - M Timothy Hresko
- Department of Orthopedic Surgery, Boston Children's Hospital, Hunnewell 2, 300 Longwood Avenue, Boston, MA, 02115, USA.,Harvard Medical School, Boston, MA, USA
| | - John B Emans
- Department of Orthopedic Surgery, Boston Children's Hospital, Hunnewell 2, 300 Longwood Avenue, Boston, MA, 02115, USA.,Harvard Medical School, Boston, MA, USA
| | - Lawrence I Karlin
- Department of Orthopedic Surgery, Boston Children's Hospital, Hunnewell 2, 300 Longwood Avenue, Boston, MA, 02115, USA.,Harvard Medical School, Boston, MA, USA
| | - Brian D Snyder
- Department of Orthopedic Surgery, Boston Children's Hospital, Hunnewell 2, 300 Longwood Avenue, Boston, MA, 02115, USA.,Harvard Medical School, Boston, MA, USA
| | - Michael P Glotzbecker
- Department of Orthopedic Surgery, Boston Children's Hospital, Hunnewell 2, 300 Longwood Avenue, Boston, MA, 02115, USA. .,Harvard Medical School, Boston, MA, USA.
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Abstract
Coverage of soft tissue defects in the upper extremity caused by infection and debridement of infected tissue is a challenging problem. Treatment starts with prompt identification and eradication of infection, including antibiotics and extensive debridement. Optimizing the patient's medical and nutritional status can facilitate eradication of infection and wound healing. Coverage of soft tissue defects caused by infection and debridement demands consideration of many factors. Options include healing by primary or secondary intention, skin grafts, local flaps, and distant flaps. Negative pressure wound therapy and acellular dermal matrices can also aid in coverage.
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Affiliation(s)
- Vanessa Prokuski
- Philadelphia Hand to Shoulder Center/Jefferson, Philadelphia, PA, USA; Orthopedic Care Physicians Network, 675 Paramount Drive, Suite 205, Raynham, MA 02767, USA
| | - Adam Strohl
- Plastic and Reconstructive Surgery, Philadelphia Hand to Shoulder Center, Thomas Jefferson University Hospital, 834 Chestnut Street, Suite G-114, Philadelphia, PA 19107, USA.
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Langsjoen J, Neuwelt A, Eberhardt S, Mlady G, Shukla U, Murali S, Pizanis C, Sillerud LO. A comparison of ferumoxytol with gadolinium as contrast agents for the diagnostic magnetic resonance imaging of osteomyelitis. Magn Reson Imaging 2020; 71:45-54. [PMID: 32439428 DOI: 10.1016/j.mri.2020.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 04/16/2020] [Accepted: 04/19/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Ferumoxytol, an FDA-approved superparamagnetic iron oxide nanoparticle (SPION) preparation used for the treatment of iron deficiency anemia, is also known to be taken up by macrophages in areas of infection or inflammation, where it produces negative contrast changes on T2-weighted MR images. PURPOSE We sought to compare Ferumoxytol-induced MRI contrast changes with those observed using standard-of-care Gadolinium in patients presenting with symptoms suggestive of osteomyelitis. SUBJECTS Out of eighteen enrolled patients, 15 had MR imaging with both ferumoxytol and gadolinium. Based on clinical and/or pathologic criteria, 7 patients were diagnosed with osteomyelitis, 5 patients had osteomyelitis ruled out, and in 3 patients a definitive diagnosis could not be made. FIELD STRENGTH 1.5 Tesla. SEQUENCES Used included STIR, T1-weighted and T2-weighted spin echo. ASSESSMENT The mean contrast changes upon ferumoxytol and gadolinium administration were measured from lesion regions of interest and compared with control regions. STATISTICAL TESTS Student's t-test, propagation of errors. Data are reported as means ± S.E. RESULTS The mean contrast changes, ΔC, associated with a diagnosis of osteomyelitis were found to be ΔCFe = -2.7 ± 0.7 when Ferumoxytol and T2w imaging sequences were used and ΔCGd = +3.1 ± 1.1 (P < 0.001) when Gadolinium and a T1w imaging sequence was used. The MRI contrast changes for both agents correlated with systemic markers of inflammation, such as the erythrocyte sedimentation rate. In patients without osteomyelitis, no significant contrast changes were observed in T2-weighted, Ferumoxytol-contrasted MRI. The macrophages in osteomyelitic lesions were found to take up at least 16 times as much iron as benign bone marrow. DATA CONCLUSION We conclude that in terms of its MRI diagnostic accuracy for osteomyelitis Ferumoxytol-contrasted MRI is a promising approach for diagnosing osteomyelitis that merits further study.
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Affiliation(s)
- Jens Langsjoen
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States of America
| | - Alex Neuwelt
- Department of Medical Oncology, Department of Veterans Affairs, Richmond, VA 23249, United States of America
| | - Stephen Eberhardt
- Department of Radiology, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States of America
| | - Gary Mlady
- Department of Radiology, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States of America
| | - Utkarsh Shukla
- University of New Mexico School of Medicine, Albuquerque, NM 87131, United States of America
| | - Sowmiya Murali
- University of New Mexico School of Medicine, Albuquerque, NM 87131, United States of America
| | - Charles Pizanis
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States of America
| | - Laurel O Sillerud
- Department of Neurology, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States of America.
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Galley J, Sutter R, Stern C, Filli L, Rahm S, Pfirrmann CWA. Diagnosis of Periprosthetic Hip Joint Infection Using MRI with Metal Artifact Reduction at 1.5 T. Radiology 2020; 296:98-108. [PMID: 32396046 DOI: 10.1148/radiol.2020191901] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background MRI with metal artifact reduction has gained importance in assessment of pain with total hip arthroplasty (THA). However, its role in diagnosis of periprosthetic joint infection (PJI) has not been well defined. Purpose To evaluate findings of PJI after THA and to determine the diagnostic performance of 1.5-T MRI with metal artifact reduction. Materials and Methods Dedicated compressed sensing-based slice encoding for metal artifact correction 1.5-T MRI examinations (from January 2015 to April 2018) in patients with THA PJI (infection group) and noninfected THA (control group) were retrospectively evaluated by two musculoskeletal radiologists. Fisher exact test was used to compare the groups. Sensitivity, specificity, and accuracy were evaluated for each finding. Interobserver reliability was assessed with κ statistics. Results Forty patients (mean age, 69 years ± 11 [standard deviation]; 26 men) in the infection group and 100 patients (mean age, 67 years ± 11; 42 men) in the control group were evaluated. Periosteal reaction, capsule edema, and intramuscular edema differed between the two groups (P < .001 for each finding). Periosteal reaction was found in 31 of 40 patients with infection and 10 of 100 participants in the control group (sensitivity, 78%; specificity, 90%; accuracy, 86%); capsule edema was found in 33 of 40 (infection group) and five of 100 (control group) (sensitivity, 83%; specificity, 95%; accuracy, 91%); and intramuscular edema was found in 38 of 40 (infection group) and 14 of 100 (control group) (sensitivity, 95%; specificity, 86%; accuracy, 89%). Interobserver agreement was almost perfect, with κ values between 0.88 and 0.92. No difference between the two groups was found regarding the presence of osteolysis (infection group, 23 of 40; control group, 60 of 100), bone marrow edema (39 of 40 vs 87 of 100), effusion (20 of 40 vs 26 of 100), abductor tendon lesion (22 of 40 vs 62 of 100), or bursitis (14 of 40 vs 34 of 100) (P > .05 for each finding). Conclusion The presence of periosteal reaction, capsule edema, and intramuscular edema after total hip arthroplasty at 1.5-T MRI with metal artifact reduction had a high accuracy in evaluation of periprosthetic joint infection. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Zanetti in this issue.
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Affiliation(s)
- Julien Galley
- From the Departments of Radiology (J.G., R.S., C.S., L.F., C.W.A.P.) and Orthopedic Surgery (S.R.), Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zürich, Switzerland; and Department of Radiology, HFR, University of Fribourg, Fribourg, Switzerland (J.G.)
| | - Reto Sutter
- From the Departments of Radiology (J.G., R.S., C.S., L.F., C.W.A.P.) and Orthopedic Surgery (S.R.), Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zürich, Switzerland; and Department of Radiology, HFR, University of Fribourg, Fribourg, Switzerland (J.G.)
| | - Christoph Stern
- From the Departments of Radiology (J.G., R.S., C.S., L.F., C.W.A.P.) and Orthopedic Surgery (S.R.), Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zürich, Switzerland; and Department of Radiology, HFR, University of Fribourg, Fribourg, Switzerland (J.G.)
| | - Lukas Filli
- From the Departments of Radiology (J.G., R.S., C.S., L.F., C.W.A.P.) and Orthopedic Surgery (S.R.), Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zürich, Switzerland; and Department of Radiology, HFR, University of Fribourg, Fribourg, Switzerland (J.G.)
| | - Stefan Rahm
- From the Departments of Radiology (J.G., R.S., C.S., L.F., C.W.A.P.) and Orthopedic Surgery (S.R.), Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zürich, Switzerland; and Department of Radiology, HFR, University of Fribourg, Fribourg, Switzerland (J.G.)
| | - Christian W A Pfirrmann
- From the Departments of Radiology (J.G., R.S., C.S., L.F., C.W.A.P.) and Orthopedic Surgery (S.R.), Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zürich, Switzerland; and Department of Radiology, HFR, University of Fribourg, Fribourg, Switzerland (J.G.)
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Nouvakis D, Natsis KS, Tsika A, Kourtesi G, Papamichalis E, Mourtzinos H. Progressive flaccid paraparesis with albuminocytologic dissociation: It's not always Gullain-Barre syndrome. J Spinal Cord Med 2020; 43:276-278. [PMID: 29939110 PMCID: PMC7054947 DOI: 10.1080/10790268.2018.1485336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
CONTEXT Spondylodiscitis, or vertebral osteomyelitis, is an unusual infection of the vertebral bodies and intervertebral discs that can occasionally present with neurological signs. FINDINGS We present a patient with subacute flaccid paraparesis with associated albuminocytologic dissociation who was eventually diagnosed with spondylodiscitis. CONCLUSION The case presented depicts a diagnostic difficulty encountered in clinical practice: Albuminocytologic dissociation in CSF is not always attributed to Guillain-Barre syndrome and other possible causes such as obstructive spinal cord lesions must always be considered.
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Affiliation(s)
| | | | - Antonia Tsika
- Department of Neurology, General Hospital of Serres, Serres, Greece
| | - Georgia Kourtesi
- Department of Neurology, General Hospital of Serres, Serres, Greece
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Altmayer S, Verma N, Dicks EA, Oliveira A. Imaging musculoskeletal soft tissue infections. Semin Ultrasound CT MR 2020; 41:85-98. [PMID: 31964497 DOI: 10.1053/j.sult.2019.09.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Musculoskeletal soft tissue infections are not uncommonly encountered in both the clinic and Emergency Department setting. The clinical diagnosis is not always evident as these infections can have variable presentations depending on the duration and depth of disease extension through the soft-tissue layers. Imaging often plays an important role in diagnosing the infection, defining the extent of involvement, directing tissue sampling, and in monitoring treatment response. After initial radiographs, ultrasound (US) is often the next modality utilized to evaluate patients with suspected soft tissue infections given its low cost, availability, portability, and potential for real-time guidance of fluid aspiration. The widespread use of cross-sectional imaging with magnetic resonance imaging (MRI) and computed tomography (CT) has greatly increased the radiological diagnosis in conditions where US may be limited. In addition, CT and MRI allow a thorough evaluation of disease extension, including assessment of joint spaces, tendons, and osseous changes indicative of bone involvement. This review will focus on the radiological findings of soft tissue infections on US, CT, and MRI.
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Affiliation(s)
- Stephan Altmayer
- Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Elizabeth A Dicks
- Department of Radiology, Imperial College Healthcare Trust, London, England
| | - Amy Oliveira
- University of Massachusetts Medical School-Baystate, Springfield, MA.
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Role of 18F-flurodeoxyglucose in orthopaedic implant-related infection: review of literature and experience. Nucl Med Commun 2020; 40:875-887. [PMID: 31365498 DOI: 10.1097/mnm.0000000000001063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Infection and inflammation are a common occurrence with orthopaedic procedures. Anatomical modalities can show the transformation in the disease process; however, these may occur later when compared with functional imaging modalities that are more likely to identify early disease patterns. Various molecular imaging modalities such as three-phase bone scintigraphy, labelled leucocyte scintigraphy, as well as radiolabelled antibiotics and immunoglobulins have been considered and have played key roles in assisting clinical decision-making. While 18F-flurodeoxyglucose (FDG) PET/computed tomography (CT) has been relatively well established in cancer pathways, it has the potential to contribute to surgical decision making for possible osteomyelitis post-metal implant surgery. In this article, we present a review of recently used tracers, and share our experience with using 18F-FDG PET/CT studies in a few diverse clinical settings related to post-metal implant osteomyelitis.
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Yusuf M, Finucane L, Selfe J. Red flags for the early detection of spinal infection in back pain patients. BMC Musculoskelet Disord 2019; 20:606. [PMID: 31836000 PMCID: PMC6911279 DOI: 10.1186/s12891-019-2949-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 11/14/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Red flags are signs and symptoms that are possible indicators of serious spinal pathology. There is limited evidence or guidance on how red flags should be used in practice. Due to the lack of robust evidence for many red flags their use has been questioned. The aim was to conduct a systematic review specifically reporting on studies that evaluated the diagnostic accuracy of red flags for Spinal Infection in patients with low back pain. METHODS Searches were carried out to identify the literature from inception to March 2019. The databases searched were Medline, CINHAL Plus, Web of Science, Embase, Cochrane, Pedro, OpenGrey and Grey Literature Report. Two reviewers screened article texts, one reviewer extracted data and details of each study, a second reviewer independently checked a random sample of the data extracted. RESULTS Forty papers met the eligibility criteria. A total of 2224 cases of spinal infection were identified, of which 1385 (62%) were men and 773 (38%) were women mean age of 55 (± 8) years. In total there were 46 items, 23 determinants and 23 clinical features. Spinal pain (72%) and fever (55%) were the most common clinical features, Diabetes (18%) and IV drug use (9%) were the most occurring determinants. MRI was the most used radiological test and Staphylococcus aureus (27%), Mycobacterium tuberculosis (12%) were the most common microorganisms detected in cases. CONCLUSION The current evidence surrounding red flags for spinal infection remains small, it was not possible to assess the diagnostic accuracy of red flags for spinal infection, as such, a descriptive review reporting the characteristics of those presenting with spinal infection was carried out. In our review, spinal infection was common in those who had conditions associated with immunosuppression. Additionally, the most frequently reported clinical feature was the classic triad of spinal pain, fever and neurological dysfunction. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non-Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Affiliation(s)
- Mohamed Yusuf
- Department of Health Professions, Manchester Metropolitan University, Manchester, M15 6GX, UK.
| | | | - James Selfe
- Department of Health Professions, Manchester Metropolitan University, Manchester, M15 6GX, UK
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Scharrenberg JS, Yagdiran A, Brinkmann J, Brune M, Siewe J, Jung N, Mahabir E. The diagnostic value of soluble urokinase-type plasminogen activator receptor (suPAR) for the discrimination of vertebral osteomyelitis and degenerative diseases of the spine. J Orthop Surg Res 2019; 14:367. [PMID: 31727136 PMCID: PMC6854784 DOI: 10.1186/s13018-019-1420-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 10/15/2019] [Indexed: 12/18/2022] Open
Abstract
Background There is still a challenge in discriminating between vertebral osteomyelitis and degenerative diseases of the spine. To this end, we determined the suitability of soluble urokinase-type plasminogen activator receptor (suPAR) and compared the diagnostic potential of suPAR to CRP. Methods Patients underwent surgical stabilization of the lumbar and/or thoracic spine with removal of one or more affected intervertebral discs, as therapy for vertebral osteomyelitis (n = 16) or for erosive osteochondrosis (control group, n = 20). In this prospective study, we evaluated the suPAR and CRP levels before (pre-OP) and after surgery (post-OP) on days 3–5, 6–11, 40–56, and 63–142. Results The suPAR levels in vertebral osteomyelitis patients were significantly higher than those from controls pre-OP, 3–5 days post-OP, and 6–11 days post-OP. Significantly higher CRP levels were observed in the vertebral osteomyelitis group than in the controls pre-OP and 6–11 days post-OP. Levels of suPAR and CRP correlated positively in all patients in the pre-OP period: r = 0.63 (95% CI: 0.37–0.79), p < 0.0001. The values for the area under the receiver operating characteristics curve (AUC) for pre-OP and the overall model post-OP were 0.88 (95% CI: 0.76–1.00) and 0.84 (95% CI: 0.71–0.97) for suPAR, 0.93 (95% CI: 0.85–1.00) and 0.77 (95% CI: 0.62–0.93) for CRP, and 0.98 (95% CI: 0.96–1.00) and 0.91 (95% CI: 0.82–1.00) for the combination of suPAR and CRP. The AUC for suPAR pre-OP revealed an optimum cut-off value, sensitivity, specificity, NPV, and PPV of 2.96 ng/mL, 0.69, 1.00, 0.80, and 1.00, respectively. For CRP, these values were 11.58 mg/L, 0.88, 0.90, 0.90, and 0.88, respectively. Conclusion The present results show that CRP is more sensitive than suPAR whereas suPAR is more specific than CRP. Moreso, our study demonstrated that improvement in the diagnostic power for discrimination of vertebral osteomyelitis and degenerative diseases of the spine can be achieved by a combination of both suPAR and CRP. Trial registration ClinicalTrials.gov, NCT02554227, posted Sept. 18, 2015, and updated Aug. 13, 2019
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Affiliation(s)
- Jan Simon Scharrenberg
- Comparative Medicine, Center for Molecular Medicine, University of Cologne, Robert-Koch-Straße 21, 50931, Cologne, Germany
| | - Ayla Yagdiran
- Department of Orthopedic and Trauma Surgery, University of Cologne, Cologne, Germany
| | - Julia Brinkmann
- Comparative Medicine, Center for Molecular Medicine, University of Cologne, Robert-Koch-Straße 21, 50931, Cologne, Germany
| | - Maik Brune
- Department of Medicine I and Clinical Chemistry, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan Siewe
- Faculty of Medicine, University Hospital, Cologne, Germany
| | - Norma Jung
- Department I of Internal Medicine, Division of Infectious Diseases, University of Cologne, Cologne, Germany
| | - Esther Mahabir
- Comparative Medicine, Center for Molecular Medicine, University of Cologne, Robert-Koch-Straße 21, 50931, Cologne, Germany.
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Walker EA, Beaman FD, Wessell DE, Cassidy RC, Czuczman GJ, Demertzis JL, Lenchik L, Motamedi K, Pierce JL, Sharma A, Ying-Kou Yung E, Kransdorf MJ. ACR Appropriateness Criteria® Suspected Osteomyelitis of the Foot in Patients With Diabetes Mellitus. J Am Coll Radiol 2019; 16:S440-S450. [DOI: 10.1016/j.jacr.2019.05.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 05/16/2019] [Indexed: 12/16/2022]
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Ojeaga PO, Hammer MR, Lindsay EA, Tareen NG, Jo CH, Copley LA. Quality Improvement of Magnetic Resonance Imaging for Musculoskeletal Infection in Children Results in Decreased Scan Duration and Decreased Contrast Use. J Bone Joint Surg Am 2019; 101:1679-1688. [PMID: 31567805 DOI: 10.2106/jbjs.19.00035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) is a heavily utilized resource to evaluate children suspected to have a musculoskeletal infection. Complex interdisciplinary workflows are involved with decision-making with regard to indications, anesthesia, contrast use, and procedural timing relative to the scan. This study assesses the impact of a quality improvement endeavor on MRI workflows at a tertiary pediatric medical center. METHODS A registry of consecutively enrolled children for a multidisciplinary musculoskeletal infection program identified those evaluated with MRI from 2012 to 2018. Annual MRI process improvement feedback was provided to the key stakeholders. Demographic characteristics, laboratory parameters, MRI indications, anesthesia use, MRI findings, final diagnoses, scan duration, imaging protocol, surgical intervention following MRI, and length of stay were retrospectively compared between the 3 cohorts (initial, middle, and final) representing 2-year increments to assess the impact of the initiative. RESULTS There were 526 original MRI scans performed to evaluate 1,845 children with suspected musculoskeletal infection. Anesthesia was used in 401 children (76.2%). When comparing the initial, middle, and final study period cohorts, significant improvement was demonstrated for the number of sequences per scan (7.5 sequences for the initial cohort, 5.8 sequences for the middle cohort, and 4.6 sequences for the final cohort; p < 0.00001), scan duration (73.6 minutes for the initial cohort, 52.1 minutes for the middle cohort, and 34.9 minutes for the final cohort; p < 0.00001), anesthesia duration (94.1 minutes for the initial cohort, 68.9 minutes for the middle cohort, and 53.2 minutes for the final cohort; p < 0.00001), and the rate of contrast use (87.6% for the initial cohort, 67.7% for the middle cohort, and 26.3% for the final cohort; p < 0.00001). There was also a trend toward a higher rate of procedures under continued anesthesia immediately following the MRI (70.2% in the initial cohort, 77.8% in the middle cohort, and 84.6% in the final cohort). During the final 6-month period, the mean scan duration was 24.4 minutes, anesthesia duration was 40.9 minutes, and the rate of contrast administration was 8.5%. CONCLUSIONS Progressive quality improvement through collaborative interdisciplinary communication and workflow redesign led to improved utilization of MRI and minimized contrast use for suspected musculoskeletal infection. There was a high rate of procedural intervention under continued anesthesia for children with confirmed musculoskeletal infection. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Patrick O Ojeaga
- University of Texas Rio Grande Valley School of Medicine, Edinburg, Texas
| | - Matthew R Hammer
- Departments of Radiology (M.R.H.), Orthopaedic Surgery (L.A.C.), and Pediatrics (L.A.C.), University of Texas Southwestern, Dallas, Texas
| | - Eduardo A Lindsay
- Department of Orthopaedic Surgery, Children's Health System of Texas, Dallas, Texas
| | - Naureen G Tareen
- Department of Orthopaedic Surgery, Children's Health System of Texas, Dallas, Texas
| | - Chan Hee Jo
- Department of Clinical Orthopaedic Research, Texas Scottish Rite Hospital for Children, Dallas, Texas
| | - Lawson A Copley
- Departments of Radiology (M.R.H.), Orthopaedic Surgery (L.A.C.), and Pediatrics (L.A.C.), University of Texas Southwestern, Dallas, Texas
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Kim J, Lee JH, Kim SW, Oh JK, Kim YW, Kim TH. Outcomes of additional instrumentation in elderly patients with pyogenic vertebral osteomyelitis and previous spinal instrumentation. Spine J 2019; 19:1498-1511. [PMID: 31108235 DOI: 10.1016/j.spinee.2019.05.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/11/2019] [Accepted: 05/13/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT In patients with pyogenic vertebral osteomyelitis (PVO) and previous instrumentation requiring surgical treatment, a decision must be made between a less-invasive noninstrumented surgery, including retaining the previous instrumentation, or a more invasive additional instrumented surgery involving the complete removal of the infected tissue and firm restabilization. PURPOSE To evaluate the clinical outcomes of using additional instrumentation in patients with PVO and previous instrumentation and determine the significant risk factors related to recurrent infection. STUDY DESIGN/SETTING Retrospective cohort study (case control study). PATIENT SAMPLE PVO patients with previous instrumentation. OUTCOME MEASURES Recurrence of PVO and mortality. METHODS Patients were divided into two groups (instrumented or noninstrumented) according to the presence or absence of additional instrumentation. The baseline characteristics, infection profile, and treatment outcomes were compared between the two groups, and a multivariate logistic regression analysis was performed to identify the risk factors for infection recurrence. RESULTS A total of 187 postoperative patients with PVO and previous spinal instrumentation were included. There were no significant differences in the baseline characteristics except the presence of a titanium cage. Surgery for additional instrumentation in patients with PVO and previous instrumentation showed similar rates of infection recurrence and mortality compared with noninstrumented surgery despite a larger number of involved vertebral levels and greater incidence of epidural abscesses. However, instrumented patients with PVO and previous instrumentation who experienced infection recurrence had worse clinical outcomes than those of the noninstrumented patients with PVO. Severe medical comorbidities, the presence of a psoas abscess, and methicillin-resistant Staphylococcus aureus infection were associated with a higher risk of infection recurrence. CONCLUSIONS Surgery for additional instrumentation in patients with PVO and previous instrumentation showed similar rates of infection recurrence and mortality to those who underwent noninstrumented surgery despite a larger number of involved vertebral levels and an increased frequency of epidural abscesses.
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Affiliation(s)
- Jihye Kim
- Division of Infection, Department of Pediatrics, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, 150, Seongan-ro, Gangdong-gu, Seoul 05355, Republic of Korea
| | - Jeong Hwan Lee
- Department of Orthopedics, Spine Center, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22, Gwanpyeong-ro, 170 beon-gil, Dongan-gu, Anyang, Gyeonggi-do 14068, Republic of Korea
| | - Seok Woo Kim
- Department of Orthopedics, Spine Center, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22, Gwanpyeong-ro, 170 beon-gil, Dongan-gu, Anyang, Gyeonggi-do 14068, Republic of Korea
| | - Jae-Keun Oh
- Department of Orthopedics, Spine Center, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22, Gwanpyeong-ro, 170 beon-gil, Dongan-gu, Anyang, Gyeonggi-do 14068, Republic of Korea
| | - Young-Woo Kim
- Department of Orthopaedic Surgery, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 7 Keunjaebong-gil, Hwaseong-si, Gyeonggi-do 18450, Republic of Korea
| | - Tae-Hwan Kim
- Department of Orthopedics, Spine Center, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22, Gwanpyeong-ro, 170 beon-gil, Dongan-gu, Anyang, Gyeonggi-do 14068, Republic of Korea.
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Sengoz T, Yaylali O, Yuksel D, Demirkan F, Uluyol O. The clinical contribution of SPECT/CT with 99mTc-HMPAO-labeled leukocyte scintigraphy in hip and knee prosthetic infections. Rev Esp Med Nucl Imagen Mol 2019. [DOI: 10.1016/j.remnie.2019.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Barakat A, Schilling WHK, Sharma S, Guryel E, Freeman R. Chronic osteomyelitis: a review on current concepts and trends in treatment. ACTA ACUST UNITED AC 2019. [DOI: 10.1016/j.mporth.2019.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Sengoz T, Yaylali O, Yuksel D, Demirkan F, Uluyol O. The clinical contribution of SPECT/CT with 99mTc-HMPAO-labeled leukocyte scintigraphy in hip and knee prosthetic infections. Rev Esp Med Nucl Imagen Mol 2019; 38:212-217. [PMID: 31147296 DOI: 10.1016/j.remn.2019.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 01/03/2019] [Accepted: 01/10/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES White blood cell scanning with 99mTc-hexamethylpropylene amine oxime (HMPAO) has proven a sensitive and specific imaging method in the diagnosis of suspected prosthesis infection. The aim of this retrospective study was to evaluate the usefulness of SPECT/CT performed simultaneously using a hybrid imaging device of prosthesis infections. MATERIALS AND METHODS 99mTc-HMPAO scintigraphy was performed on 37 patients (11 men and 26 women; age range 38-84 years; mean age±SD, 65.7±5.6 years). Planar scans were acquired 2.4 and 24hour after injection. SPECT/CT was obtained 4 h after injection, using a dual-head hybrid gama camera coupled with a low-power x-ray tube. In all patients, scintigraphic results were matched with the results of surgery, cultures and clinical follow-up. RESULTS Seventeen (45,9%) out of 37 patients had prosthesis infection and 20 (54,1%) out of 37 patients had non-infectious prosthesis pathologies with 99mTc-HMPAO scintigraphy and SPECT/CT. The 99mTc-HMPAO scintigraphy was true-positive for infection in 16 of 37 patients and true-negative in 20 of 37 patients. SPECT/CT provided an accurate anatomic localization of all positive foci. With regard to the final diagnosis, SPECT/CT added a significant clinical contribution in 22 of 37 patients (59,4%). Sensitivity, specificity, negative predictive value and positive predictive values were 100%,59.1%,100%,62.5% in planar images with 99mTc-HMPAO scintigraphy and 100%,90.1%,100%,88.2% in the planar+SPECT/CT imaging, respectively. DISCUSSION Our results indicate that SPECT/CT performed using a hybrid device can improve imaging with 99mTc-HMPAO scintigraphy in patients with suspected osteomyelitis by providing accurate anatomic localization and precise definition of the extent of infection.
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Affiliation(s)
- T Sengoz
- Pamukkale University, Medical Faculty, Department of Nuclear Medicine, Denizli, Turquía.
| | - O Yaylali
- Pamukkale University, Medical Faculty, Department of Nuclear Medicine, Denizli, Turquía
| | - D Yuksel
- Pamukkale University, Medical Faculty, Department of Nuclear Medicine, Denizli, Turquía
| | - F Demirkan
- Pamukkale University, Medical Faculty, Department of Orthopedics, Denizli, Turquía
| | - O Uluyol
- Pamukkale University, Medical Faculty, Department of Nuclear Medicine, Denizli, Turquía
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Kamiya N, Hatakeyama S, Kanda N, Yonaha S, Akine D, Yamamoto Y, Matsumura M. Significance of repeat magnetic resonance imaging in diagnosing vertebral osteomyelitis. J Gen Fam Med 2019; 20:68-71. [PMID: 30873308 PMCID: PMC6399723 DOI: 10.1002/jgf2.226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 11/12/2018] [Accepted: 11/24/2018] [Indexed: 01/26/2023] Open
Abstract
Vertebral osteomyelitis can result in serious complications if diagnosis is delayed. Magnetic resonance imaging (MRI) is considered the most useful modality for the early diagnosis of vertebral osteomyelitis. We examined three patients with vertebral osteomyelitis whose initial MRI (obtained <2 weeks after the onset of symptoms) did not reveal obvious findings of pyogenic vertebral osteomyelitis. However, follow-up MRI clearly demonstrated typical findings of the disease. This case series illustrates that a repeat MRI must be performed 2-4 weeks after the onset of symptoms in patients presenting with clinical manifestations and microbiological findings suggestive of vertebral osteomyelitis.
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Affiliation(s)
- Naoko Kamiya
- Division of General Internal MedicineJichi Medical University HospitalTochigiJapan
| | - Shuji Hatakeyama
- Division of General Internal MedicineJichi Medical University HospitalTochigiJapan
- Division of Infectious DiseasesJichi Medical University HospitalTochigiJapan
| | - Naoki Kanda
- Division of General Internal MedicineJichi Medical University HospitalTochigiJapan
| | - Sho Yonaha
- Division of General Internal MedicineJichi Medical University HospitalTochigiJapan
| | - Dai Akine
- Division of General Internal MedicineJichi Medical University HospitalTochigiJapan
- Division of Infectious DiseasesJichi Medical University HospitalTochigiJapan
| | - Yu Yamamoto
- Division of General Internal MedicineJichi Medical University HospitalTochigiJapan
| | - Masami Matsumura
- Division of General Internal MedicineJichi Medical University HospitalTochigiJapan
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Kim J, Jang SB, Kim SW, Oh JK, Kim TH. Clinical effect of early bisphosphonate treatment for pyogenic vertebral osteomyelitis with osteoporosis: An analysis by the Cox proportional hazard model. Spine J 2019; 19:418-429. [PMID: 30172897 DOI: 10.1016/j.spinee.2018.08.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Patients with pyogenic vertebral osteomyelitis (PVO) are expected to have an increased risk of bone loss. Therefore, early bisphosphonate therapy would be clinically effective for PVO patients with osteoporosis. PURPOSE This study aimed to investigate the effect of bisphosphonate on clinical outcomes of PVO patients with osteoporosis. STUDY DESIGN/SETTING A retrospective comparative study. PATIENT SAMPLE PVO patients with osteoporosis. OUTCOME MEASURES Four events of interest for Cox proportional hazard model included surgical treatment, recurrence of infection, subsequent fracture of adjacent vertebral bodies, and death. METHODS PVO patients were divided into three groups: group A (initiation of bisphosphonate within 6 weeks after PVO diagnosis), group B (initiation of bisphosphonate between 6 weeks and 3 months after PVO diagnosis), and group C (no treatment for osteoporosis). Cox proportional hazard model was used for the four events of interest. RESULTS A total of 360 PVO patients with osteoporosis were investigated for the four events of interest. Group A had significantly lower hazard ratios for undergoing later (>6 weeks after diagnosis) surgery than group C (p = .014) despite similar occurrences of overall surgery. A significant difference was also observed in the occurrence of subsequent fractures at adjacent vertebral bodies (p = .001 for model 1 and p = .002 for model 2). Groups A and B had significantly lower hazard ratios for subsequent fracture than group C. No significant differences were observed in the hazard ratios of recurrence and death among the three groups. CONCLUSIONS Early bisphosphonate treatment in PVO patients with osteoporosis was associated with a significantly lower occurrence of subsequent vertebral fracture at adjacent vertebral bodies and lower occurrence of subsequent surgery.
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Affiliation(s)
- Jihye Kim
- Division of Infection, Department of Pediatrics, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, South Korea
| | - Seung Bo Jang
- Spine Center, Department of Orthopedics, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 896, Pyeongchon-Dong, Anyang, Gyeonggi-Do 431-070, South Korea
| | - Seok Woo Kim
- Spine Center, Department of Orthopedics, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 896, Pyeongchon-Dong, Anyang, Gyeonggi-Do 431-070, South Korea
| | - Jae-Keun Oh
- Spine Center, Department of Orthopedics, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 896, Pyeongchon-Dong, Anyang, Gyeonggi-Do 431-070, South Korea
| | - Tae-Hwan Kim
- Spine Center, Department of Orthopedics, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 896, Pyeongchon-Dong, Anyang, Gyeonggi-Do 431-070, South Korea.
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Diaz-Ledezma C, Espinosa-Mendoza R, Gallo J, Glaudemans A, Gómez-García F, Goodman S, Kaminek M, Le Roux TLB, Llinás A, Nieslanikova E, Quinn L, Sculco P, Svoboda M. General Assembly, Diagnosis, Imaging: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S215-S223. [PMID: 30360979 DOI: 10.1016/j.arth.2018.09.073] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Pawaskar A, Basu S, Jahangiri P, Alavi A. In Vivo Molecular Imaging of Musculoskeletal Inflammation and Infection. PET Clin 2018; 14:43-59. [PMID: 30420221 DOI: 10.1016/j.cpet.2018.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In vivo molecular imaging detects biologic processes at molecular level and provides diagnostic information at an earlier time point during disease onset or repair. It offers definite advantage over anatomic imaging in terms of improved sensitivity and ability to quantify. Radionuclide molecular imaging has been widely used in clinical practice. This article discusses the role of radionuclide imaging in various infective and inflammatory diseases affecting musculoskeletal system with a focus on PET. It appears that, as more data become available, combined PET/MR imaging could emerge as a front runner in the imaging of musculoskeletal infection and inflammation.
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Affiliation(s)
- Alok Pawaskar
- Oncolife Cancer Centre, Satara, Maharashtra 415519, India; Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Centre Annexe, Parel, Mumbai, Maharashtra 400012, India
| | - Sandip Basu
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Centre Annexe, Parel, Mumbai, Maharashtra 400012, India; Homi Bhabha National Institute, Mumbai, Maharashtra, India.
| | - Pegah Jahangiri
- Division of Nuclear Medicine, Hospital of University of Pennsylvania, Philadelphia, PA, USA
| | - Abass Alavi
- Division of Nuclear Medicine, Hospital of University of Pennsylvania, Philadelphia, PA, USA
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Safdar NM, Rigsby CK, Iyer RS, Alazraki AL, Anupindi SA, Bardo DME, Brown BP, Chan SS, Chandra T, Dillman JR, Dorfman SR, Garber MD, Lam HFS, Nguyen JC, Siegel A, Widmann RF, Karmazyn B. ACR Appropriateness Criteria ® Acutely Limping Child Up To Age 5. J Am Coll Radiol 2018; 15:S252-S262. [PMID: 30392594 DOI: 10.1016/j.jacr.2018.09.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 09/07/2018] [Indexed: 11/19/2022]
Abstract
Imaging plays in important role in the evaluation of the acutely limping child. The decision-making process about initial imaging must consider the level of suspicion for infection and whether symptoms can be localized. The appropriateness of specific imaging examinations in the acutely limping child to age 5 years is discussed with attention in each clinical scenario to the role of radiography, ultrasound, nuclear medicine, computed tomography, and magnetic resonance imaging. Common causes of limping such as toddler's fracture, septic arthritis, transient synovitis, and osteomyelitis are discussed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Cynthia K Rigsby
- Panel Chair, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Ramesh S Iyer
- Panel Vice-Chair, Seattle Children's Hospital, Seattle, Washington
| | | | | | | | - Brandon P Brown
- Riley Hospital for Children Indiana University, Indianapolis, Indiana
| | | | | | | | | | - Matthew D Garber
- Wolfson Children's Hospital, Jacksonville, Florida; American Academy of Pediatrics
| | - H F Samuel Lam
- Sutter Medical Center Sacramento, Sacramento, California; American College of Emergency Physicians
| | - Jie C Nguyen
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alan Siegel
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Roger F Widmann
- Hospital for Special Surgery, New York, New York; American Academy of Orthopaedic Surgeons
| | - Boaz Karmazyn
- Specialty Chair, Riley Hospital for Children Indiana University, Indianapolis, Indiana
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Kwon JW, Hyun SJ, Han SH, Kim KJ, Jahng TA. Pyogenic Vertebral Osteomyelitis: Clinical Features, Diagnosis, and Treatment. KOREAN JOURNAL OF SPINE 2017; 14:27-34. [PMID: 28704905 PMCID: PMC5518432 DOI: 10.14245/kjs.2017.14.2.27] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 04/07/2017] [Accepted: 06/20/2017] [Indexed: 12/18/2022]
Abstract
Pyogenic vertebral osteomyelitis (PVO) may result in neurological deficits and sequelae, so early diagnosis and appropriate treatment are critical. Many previous studies on PVO exist, but our paper has aimed to comprehensively summarize the clinical aspects of PVO. Through review of the vast literature on the clinical research of PVO an overview of the clinical characteristics, diagnostic methods, treatment and prognosis is provided.
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Affiliation(s)
- Ji-Woong Kwon
- Neuro-Oncology Clinic, National Cancer Center, Goyang, Korea
| | - Seung-Jae Hyun
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Sang-Hyun Han
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Ki-Jeong Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Tae-Ahn Jahng
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Abstract
Septic arthritis and spondylodiscitis are relatively rare but severe diseases with increasing incidence. Septic arthritis is an emergency situation with high morbidity (40 %) and fatality rates (11 %). The infection occurs via a hematogenous route by direct inoculation or per continuitatem. Patients with pre-existing destructive joint diseases or under immunosuppressive treatment are particularly at risk. It is mandatory to sample synovial fluid for isolation of the relevant pathogen and quantification of leucocytes before starting antibiotic therapy. In order to preserve the joint, early evacuation of the infected synovial space is necessary. Spondylodiscitis is characterized by infection of the vertebra and neighboring discs mainly via a hematogenous route. Immunosuppressed and older patients are primarily at risk of infection. Back pain represents the main symptom but due to its unspecific character and the frequent absence of fever, diagnosis is often delayed. In Europe Staphylococcus aureus is the most prevalent pathogen, whereas tuberculosis is the most frequent causal agent worldwide. Magnetic resonance imaging (MRI) respresents the method of choice for the radiological diagnostics. In stable patients isolation of the pathogen should be achieved before starting antimicrobial therapy (e.g. blood cultures or tissue samples by computed tomography guided puncture or biopsy). The recommended duration of pathogen-specific antibiotic therapy for native spondylodiscitis is normally 6 weeks.
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Affiliation(s)
- N Jung
- Klinik 1 für Innere Medizin, Universitätsklinikum Köln, Kerpener Str. 62, 50935, Köln, Deutschland.
| | - S Vossen
- Plastische, Ästhetische und Handchirurgie, Franziskushospital Aachen, 52074, Aachen, Deutschland
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Beaman FD, von Herrmann PF, Kransdorf MJ, Adler RS, Amini B, Appel M, Arnold E, Bernard SA, Greenspan BS, Lee KS, Tuite MJ, Walker EA, Ward RJ, Wessell DE, Weissman BN. ACR Appropriateness Criteria ® Suspected Osteomyelitis, Septic Arthritis, or Soft Tissue Infection (Excluding Spine and Diabetic Foot). J Am Coll Radiol 2017; 14:S326-S337. [DOI: 10.1016/j.jacr.2017.02.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 01/30/2017] [Accepted: 02/02/2017] [Indexed: 11/28/2022]
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Govaert GA, IJpma FF, McNally M, McNally E, Reininga IH, Glaudemans AW. Accuracy of diagnostic imaging modalities for peripheral post-traumatic osteomyelitis - a systematic review of the recent literature. Eur J Nucl Med Mol Imaging 2017; 44:1393-1407. [PMID: 28451827 PMCID: PMC5486824 DOI: 10.1007/s00259-017-3683-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 03/16/2017] [Indexed: 12/20/2022]
Abstract
AIMS Post-traumatic osteomyelitis (PTO) is difficult to diagnose and there is no consensus on the best imaging strategy. The aim of this study is to present a systematic review of the recent literature on diagnostic imaging of PTO. METHODS A literature search of the EMBASE and PubMed databases of the last 16 years (2000-2016) was performed. Studies that evaluated the accuracy of magnetic resonance imaging (MRI), three-phase bone scintigraphy (TPBS), white blood cell (WBC) or antigranulocyte antibody (AGA) scintigraphy, fluorodeoxyglucose positron emission tomography (FDG-PET) and plain computed tomography (CT) in diagnosing PTO were considered for inclusion. The review was conducted using the PRISMA statement and QUADAS-2 criteria. RESULTS The literature search identified 3358 original records, of which 10 articles could be included in this review. Four of these studies had a comparative design which made it possible to report the results of, in total, 17 patient series. WBC (or AGA) scintigraphy and FDG-PET exhibit good accuracy for diagnosing PTO (sensitivity ranged from 50-100%, specificity ranged from 40-97% versus 83-100% and 51%-100%, respectively). The accuracy of both modalities improved when a hybrid imaging technique (SPECT/CT & FDG-PET/CT) was performed. For FDG-PET/CT, sensitivity ranged between 86 and 94% and specificity between 76 and 100%. For WBC scintigraphy + SPECT/CT, this is 100% and 89-97%, respectively. CONCLUSIONS Based on the best available evidence of the last 16 years, both WBC (or AGA) scintigraphy combined with SPECT/CT or FDG-PET combined with CT have the best diagnostic accuracy for diagnosing peripheral PTO.
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Affiliation(s)
- Geertje A Govaert
- Department of Surgery, Subdivision of Trauma Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands. .,Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Room number G.04.228, P.O. Box 85500, 3508, GA, Utrecht, The Netherlands.
| | - Frank F IJpma
- Department of Surgery, Subdivision of Trauma Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Martin McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Inge H Reininga
- Department of Surgery, Subdivision of Trauma Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Andor W Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Chun CW, Jung JY, Baik JS, Jee WH, Kim SK, Shin SH. Detection of soft-tissue abscess: Comparison of diffusion-weighted imaging to contrast-enhanced MRI. J Magn Reson Imaging 2017; 47:60-68. [PMID: 28432835 DOI: 10.1002/jmri.25743] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 04/05/2017] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To compare the diagnostic performances of diffusion-weighted imaging (DWI)-combined magnetic resonance imaging (MRI) performed without intravenous contrast material with gadolinium contrast material-enhanced (CE) MRI for diagnosing soft-tissue abscesses. MATERIALS AND METHODS In all, 119 patients (mean age: 56 years) with skin and soft-tissue infection who underwent contrast-enhanced MRI with DWI (b = 0-800) were included. Two readers independently reviewed both image sets-nonenhanced conventional MR images (NECI)+DWI, and NECI+contrast enhanced fat-suppressed T1 -weighted imaging (CEFST1 )-for the presence of abscess. To compare the diagnostic performance for diagnosing abscess between NECI+DWI, and NECI+CEFST1 , McNemar tests for sensitivity and specificity, and areas under the receiver-operating characteristic curves (AUC) analyses, were performed. Interobserver agreements (κ) were calculated for each image set. RESULTS Forty of 119 patients were confirmed with abscess. Sensitivity and specificity were 90.0% and 88.6% for NECI+DWI, and 82.5% and 89.9% for NECI+CEFST1 in reader 1, whereas 77.5% and 88.6% for NECI+DWI, and 80.0% and 84.8% for NECI+CEFST1 in reader 2, respectively. There was no significant difference in sensitivities and specificities between NECI+DWI and NECI+CEFST1 (reader 1: P = 0.453, P = 0.999, reader 2: P = 0.999, P = 0.453, respectively). Likewise, AUC analyses demonstrated no significant difference between NECI+DWI and NECI+CEFST1 (P = 0.53 in reader 1, P = 0.97 in reader 2). Interobserver agreement between the two readers was substantial in both image sets: 0.80 (NECI+DWI), and 0.76 (NECI+CEFST1 ). CONCLUSION Noncontrast-enhanced MRI with DWI has comparable diagnostic performance to contrast-enhanced MRI for diagnosing soft-tissue abscesses. LEVEL OF EVIDENCE 3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;47:60-68.
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Affiliation(s)
- Chang Woo Chun
- Department of Radiology, Uijeongbu St. Mary's Hospital, Uijeongbu, Korea
| | - Joon-Yong Jung
- Department of Radiology, Seoul St. Mary's Hospital, Seoul, Korea
| | - Jun Seung Baik
- Department of Radiology, Seoul St. Mary's Hospital, Seoul, Korea
| | - Won-Hee Jee
- Department of Radiology, Seoul St. Mary's Hospital, Seoul, Korea
| | - Sun Ki Kim
- Department of Radiology, Incheon St. Mary's Hospital, Incheon, Korea
| | - Seung Han Shin
- Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Abstract
Imaging is often used to establish a diagnosis of musculoskeletal infections and evaluate the full extent and severity of disease. Imaging should always start with radiographs, which provide an important anatomic overview. MRI is the test of choice in most musculoskeletal infections because of its superior soft tissue contrast resolution and high sensitivity for pathologic edema. However, MRI is not always possible. Alternative imaging modalities including ultrasound scan, computed tomography, and radionuclide imaging may be used. This article reviews the individual imaging modalities and discusses how specific musculoskeletal infections should be approached from an imaging perspective.
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Affiliation(s)
- Claus S Simpfendorfer
- Section of Musculoskeletal Radiology, Imaging Institute, Cleveland Clinic, CCLCM/CWRU, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Wenter V, Albert NL, Brendel M, Fendler WP, Cyran CC, Bartenstein P, Friederichs J, Müller JP, Militz M, Hacker M, Hungerer S. [ 18F]FDG PET accurately differentiates infected and non-infected non-unions after fracture fixation. Eur J Nucl Med Mol Imaging 2016; 44:432-440. [PMID: 27704194 PMCID: PMC5591625 DOI: 10.1007/s00259-016-3528-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 09/13/2016] [Indexed: 11/28/2022]
Abstract
Purpose Complete fracture healing is crucial for good patient outcomes. A major complication in the treatment of fractures is non-union. The pathogenesis of non-unions is not always clear, although implant-associated infections play a significant role, especially after surgical treatment of open fractures. We aimed to evaluate the value of [18F]FDG PET in suspected infections of non-union fractures. Methods We retrospectively evaluated 35 consecutive patients seen between 2000 and 2015 with suspected infection of non-union fractures, treated at a level I trauma center. The patients underwent either [18F]FDG PET/CT (N = 24), [18F]FDG PET (N = 11) plus additional CT (N = 8), or conventional X-ray (N = 3). Imaging findings were correlated with final diagnosis based on intraoperative culture or follow-up. Results In 13 of 35 patients (37 %), infection was proven by either positive intraoperative tissue culture (N = 12) or positive follow-up (N = 1). [18F]FDG PET revealed 11 true-positive, 19 true-negative, three false-positive, and two false-negative results, indicating sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of 85 %, 86 %, 79 %, 90 %, and 86 %, respectively. The SUVmax was 6.4 ± 2.7 in the clinically infected group and 3.0 ± 1.7 in the clinically non-infected group (p <0.01). The SUVratio was 5.3 ± 3.3 in the clinically infected group and 2.6 ± 1.5 in the clinically non-infected group (p <0.01). Conclusion [18F]FDG PET differentiates infected from non-infected non-unions with high accuracy in patients with suspected infections of non-union fractures, for whom other clinical findings were inconclusive for a local infection. [18F]FDG PET should be considered for therapeutic management of non-unions.
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Affiliation(s)
- Vera Wenter
- Department of Nuclear Medicine, University of Munich, Munich, Germany
| | - Nathalie L Albert
- Department of Nuclear Medicine, University of Munich, Munich, Germany
| | - Matthias Brendel
- Department of Nuclear Medicine, University of Munich, Munich, Germany
| | | | - Clemens C Cyran
- Institute for Clinical Radiology, University of Munich, Munich, Germany
| | - Peter Bartenstein
- Department of Nuclear Medicine, University of Munich, Munich, Germany
| | - Jan Friederichs
- Department of Reconstructive Arthroplasty, BG Trauma Center Murnau, Murnau, Germany.,Paracelsus Medical University, PMU Salzburg, Salzburg, Austria
| | - Jan-Philipp Müller
- Department of Reconstructive Arthroplasty, BG Trauma Center Murnau, Murnau, Germany.,Paracelsus Medical University, PMU Salzburg, Salzburg, Austria
| | - Matthias Militz
- Department of Reconstructive Arthroplasty, BG Trauma Center Murnau, Murnau, Germany.,Paracelsus Medical University, PMU Salzburg, Salzburg, Austria
| | - Marcus Hacker
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-guided Therapy, University of Vienna, Währinger Gürtel 18-20, Floor 5L, 1090, Vienna, Austria.
| | - Sven Hungerer
- Department of Reconstructive Arthroplasty, BG Trauma Center Murnau, Murnau, Germany.,Paracelsus Medical University, PMU Salzburg, Salzburg, Austria
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Palestro CJ. Radionuclide Imaging of Musculoskeletal Infection: A Review. J Nucl Med 2016; 57:1406-12. [PMID: 27390160 DOI: 10.2967/jnumed.115.157297] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 06/29/2016] [Indexed: 12/12/2022] Open
Abstract
There are numerous imaging tests for diagnosing musculoskeletal infection. Radiographs are routinely performed, because even when not diagnostic, they provide an anatomic overview of the region of interest that could influence subsequent procedure selection and interpretation. MRI is sensitive and provides superb anatomic detail. Bone scintigraphy accurately diagnoses osteomyelitis in bones not affected by underlying conditions. (67)Ga is used primarily for spondylodiskitis. Although in vitro labeled leukocyte imaging is the radionuclide test of choice for complicating osteomyelitis such as diabetic pedal osteomyelitis and prosthetic joint infection, it is not useful for spondylodiskitis. Antigranulocyte antibodies and antibody fragments have limitations and are not widely available. (111)In-biotin is useful for spondylodiskitis. Radiolabeled synthetic fragments of the antimicrobial peptide ubiquicidin are promising infection-specific agents. (18)F-FDG is the radiopharmaceutical of choice for spondylodiskitis. Its role in diabetic pedal osteomyelitis and prosthetic joint infection is not established. Preliminary data suggest (68)Ga may be useful in musculoskeletal infection. (124)I-fialuridine initially showed promise as an infection-specific radiopharmaceutical, but subsequent investigations were disappointing. The development of PET/CT and SPECT/CT imaging systems, which combine anatomic and functional imaging, has revolutionized diagnostic imaging. These hybrid systems are redefining the diagnostic workup of patients with suspected or known infection and inflammation by improving diagnostic accuracy and influencing patient management.
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Mantovani A, Trombetta M, Imbriaco C, Rigolon R, Mingolla L, Zamboni F, Dal Molin F, Cioccoloni D, Sanga V, Bruti M, Brocco E, Conti M, Ravenna G, Perrone F, Stoico V, Bonora E. Diabetic foot complicated by vertebral osteomyelitis and epidural abscess. Endocrinol Diabetes Metab Case Rep 2016; 2016:150132. [PMID: 27252859 PMCID: PMC4872002 DOI: 10.1530/edm-15-0132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 04/21/2016] [Indexed: 12/18/2022] Open
Abstract
UNLABELLED Vertebral osteomyelitis (or spondylodiscitis) is steadily increasing in Western countries and often results from hematogenous seeding, direct inoculation during spinal surgery, or contiguous spread from an infection in the adjacent soft tissue. We present the case of a 67-year-old white patient with type 2 diabetes who went to Hospital for high fever, back pain, and worsening of known infected ulcers in the left foot. Despite intravenous antibiotic treatment and surgical debridement of the foot infection, high fever and lower back pain continued. Bone biopsy and two consecutive blood cultures were positive for Staphylococcus aureus. A spinal magnetic resonance imaging (MRI) was performed, revealing serious osteomyelitis in L4 and L5 complicated by an epidural abscess. Contiguous or other distant focuses of infection were not identified. In this case, diabetic foot could be considered as a primary distant focus for vertebral osteomyelitis. Clinicians should consider vertebral osteomyelitis as a 'possible' diagnosis in patients with type 2 diabetes complicated by foot infection that is associated with fever and lower back pain. LEARNING POINTS Vertebral osteomyelitis is increasing in Western countries, especially in patients with type 2 diabetes.The primary focus of infection is the genitourinary tract followed by skin, soft tissue, endocarditis, bursitis, septic arthritis, and intravascular access.Diabetic foot could be a rare primary focus of infection for vertebral osteomyelitis, and, however, vertebral osteomyelitis could be a serious, albeit rare, complication of diabetic foot.Clinicians should keep in mind the many potential complications of diabetic foot ulcerations and consider vertebral osteomyelitis as a "possible" diagnosis in patients with type 2 diabetes and foot ulcers associated with nonspecific symptoms such as lower back pain.Early diagnosis and correct management of vertebral osteomyelitis are crucial to improve clinical outcomes.
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Affiliation(s)
- Alessandro Mantovani
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona , Verona , Italy
| | - Maddalena Trombetta
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona , Verona , Italy
| | - Chiara Imbriaco
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona , Verona , Italy
| | - Riccardo Rigolon
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona , Verona , Italy
| | - Lucia Mingolla
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona , Verona , Italy
| | - Federica Zamboni
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona , Verona , Italy
| | - Francesca Dal Molin
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona , Verona , Italy
| | - Dario Cioccoloni
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona , Verona , Italy
| | - Viola Sanga
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona , Verona , Italy
| | - Massimiliano Bruti
- Division of Plastic Surgery, Department of Surgery, University and Azienda Ospedaliera Universitaria Integrata of Verona , Verona , Italy
| | - Enrico Brocco
- Regional Referral Center for the Treatment of Diabetic Foot , Policlinico Abano Terme, Padova , Italy
| | - Michela Conti
- Division of Infectious Disease, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona , Verona , Italy
| | - Giorgio Ravenna
- Division of Neurosurgery, Department of Surgery, University and Azienda Ospedaliera Universitaria Integrataof Verona , Verona , Italy
| | - Fabrizia Perrone
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona , Verona , Italy
| | - Vincenzo Stoico
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona , Verona , Italy
| | - Enzo Bonora
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona , Verona , Italy
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41
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Abstract
This article discusses the role of [(18)F]Fluorodeoxyglucose (FDG) PET and PET/computed tomography in diagnosis and therapeutic response assessment for the management of patients with osteomyelitis, to increase awareness of imaging pitfalls and to improve understanding of specific technical and diagnostic challenges in patients with posttraumatic chronic osteomyelitis, spinal infections, prosthetic joint infections, and diabetic foot infections. This article focuses on the usefulness of modern imaging modalities in the setting of suspected infection or inflammation and on the role of FDG-PET in the management of patients with suspected or confirmed infection in the bones.
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Dauchy FA, Dutertre A, Lawson-Ayayi S, de Clermont-Gallerande H, Fournier C, Zanotti-Fregonara P, Dutronc H, Vital JM, Dupon M, Fernandez P. Interest of [(18)F]fluorodeoxyglucose positron emission tomography/computed tomography for the diagnosis of relapse in patients with spinal infection: a prospective study. Clin Microbiol Infect 2016; 22:438-43. [PMID: 26802215 DOI: 10.1016/j.cmi.2015.12.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 12/13/2015] [Accepted: 12/20/2015] [Indexed: 11/15/2022]
Abstract
Relapse after treatment of a spinal infection is infrequent and difficult to diagnose. The aim of this study was to assess the diagnostic performance of [(18)F]fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) in this setting. Thirty patients (21 men, nine women; median age 61.2 years) with a suspected spinal infection relapse were prospectively included between March 2010 and June 2013. The initial diagnosis of spinal infection was confirmed by positive bacterial cultures. The patients underwent [(18)F]FDG PET/CT and magnetic resonance imaging (MRI) 1 month after antibiotic treatment interruption. PET/CT data were interpreted both visually and semi-quantitatively (SUVmax). The patients were followed for ≥12 months and the final diagnosis of relapse was based on new microbiological cultures. Seven patients relapsed during follow up. Sensitivity, specificity, positive predictive value and negative predictive value were 66.6%, 61.9%, 33.3% and 86.6%, respectively for MRI and 85.7, 82.6, 60.0 and 95.0 for PET/CT. Although these values were higher for PET/CT than for MRI, the difference was not statistically significant (p=0.3). [(18)F]FDG PET/CT may be useful for diagnosing a relapse of spinal infections, in particular if metallic implants limit the performance of MRI.
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Affiliation(s)
- F-A Dauchy
- Department of Infectious and Tropical Diseases, University Hospital of Bordeaux, Bordeaux, France.
| | - A Dutertre
- Department of Nuclear Medicine, University Hospital of Bordeaux, Bordeaux, France
| | - S Lawson-Ayayi
- INSERM, ISPED, Centre INSERM U897-Epidémiologie-Biostatistique, Bordeaux, France
| | | | - C Fournier
- Department of Diagnostic and Interventional Imaging, University Hospital of Bordeaux, Bordeaux, France
| | - P Zanotti-Fregonara
- Department of Nuclear Medicine, University Hospital of Bordeaux, Bordeaux, France
| | - H Dutronc
- Department of Infectious and Tropical Diseases, University Hospital of Bordeaux, Bordeaux, France
| | - J-M Vital
- Spine Unit One, Orthopaedic Surgery, University Hospital of Bordeaux, Bordeaux, France
| | - M Dupon
- Department of Infectious and Tropical Diseases, University Hospital of Bordeaux, Bordeaux, France
| | - P Fernandez
- Department of Nuclear Medicine, University Hospital of Bordeaux, Bordeaux, France
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43
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Yadavalli S. Radiologic Evaluation of Musculoskeletal Soft Tissue Infections: A Pictorial Review. CURRENT RADIOLOGY REPORTS 2015. [DOI: 10.1007/s40134-015-0119-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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44
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Yoon HY, Park SH, Jeung SM, Seo YR, Seo BM, Kim SH, Yoo B. A Case of Cardiac Behçet’s Disease Mimicking Culture-Negative Infective Endocarditis. ACTA ACUST UNITED AC 2015. [DOI: 10.3904/kjm.2015.89.2.249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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45
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Abstract
Radionuclide procedures frequently are performed as part of the diagnostic workup of osteomyelitis. Bone scintigraphy accurately diagnoses osteomyelitis in bones not affected by underlying conditions. Degenerative joint disease, fracture, and orthopedic hardware decrease the specificity of the bone scan, making it less useful in these situations. Gallium-67 scintigraphy was often used as an adjunct to bone scintigraphy for diagnosing osteomyelitis. However, now it is used primarily for spinal infections when (18)F-FDG imaging cannot be performed. Except for the spine, in vitro-labeled leukocyte imaging is the nuclear medicine test of choice for diagnosing complicating osteomyelitis. Leukocytes accumulate in bone marrow as well as in infection. Performing complementary bone marrow imaging with (99m)Tc-sulfur colloid facilitates the differentiation between osteomyelitis and normal marrow and improves test overall accuracy. Antigranulocyte antibodies and antibody fragments, such as (99m)Tc-besilesomab and (99m)Tc-sulesomab, were developed to eliminate the disadvantages associated with in vitro-labeled leukocytes. These agents, however, have their own shortcomings and are not widely available. As biotin is used as a growth factor by certain bacteria, (111)In-biotin is useful to diagnose spinal infections. Radiolabeled synthetic fragments of ubiquicidin, a naturally occurring human antimicrobial peptide that targets bacteria, can differentiate infection from sterile inflammation and may be useful to monitor response to treatment. (18)F-FDG is extremely useful in the diagnostic workup of osteomyelitis. Sensitivity in excess of 95% and specificity ranging from 75%-99% have been reported. (18)F-FDG is the radionuclide test of choice for spinal infection. The test is sensitive, with a high negative predictive value, and reliably differentiates degenerative from infectious vertebral body end-plate abnormalities. Data on the accuracy of (18)F-FDG for diagnosing diabetic pedal osteomyelitis are contradictory, and its role for this indication remains to be determined. Initial investigations suggested that (18)F-FDG accurately diagnoses prosthetic joint infection; more recent data indicate that it cannot differentiate infection from other causes of prosthetic failure. Preliminary data on the PET agents gallium-68 and iodine-124 fialuridine indicate that these agents may have a role in diagnosing osteomyelitis.
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Affiliation(s)
- Christopher J Palestro
- Department of Radiology Hofstra, NorthShore-LIJ School of Medicine, Hempstead, NY; Division of Nuclear Medicine and Molecular Imaging, North Shore Long Island Jewish Health System, Manhasset & New Hyde Park, NY.
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46
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Georgakopoulos A, Pneumaticos SG, Sipsas NV, Chatziioannou S. Positron emission tomography in spinal infections. Clin Imaging 2015; 39:553-8. [PMID: 25914050 DOI: 10.1016/j.clinimag.2015.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 04/05/2015] [Indexed: 11/15/2022]
Abstract
Magnetic resonance imaging is the imaging method of choice for diagnosing infection of the spine in unoperated cases. 2-[(18)F]-fluoro-2deoxy-d-glucose positron emission tomography/computed tomography study is recommended to distinguish between spinal infection and common Modic change in patients with metallic implants and prosthetic replacements and for differentiating tuberculous from pyogenic spondylitis in ambiguous cases, reflecting the activity of the infection. Also, it seems to have a strong clinical impact in more than half of patients with infectious spondylitis, while it is superior to other imaging techniques in revealing residual disease after treatment and early response to therapy. New tracers as well as new hybrid modalities are under investigation.
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Affiliation(s)
- Alexandros Georgakopoulos
- Nuclear Medicine Division, PET/CT section, Foundation for Biomedical Research of the Academy of Athens, Athens, Greece.
| | - Spiros G Pneumaticos
- 3rd Department of Orthopedic Surgery, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos V Sipsas
- Department of Pathophysiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Sofia Chatziioannou
- Nuclear Medicine Division, PET/CT section, Foundation for Biomedical Research of the Academy of Athens, Athens, Greece; Second Department of Radiology, Medical School, National and Kapodistrian University of Athens, General University Hospital "ATTIKON", Athens, Greece
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47
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Saboo SS, Lin YC, Juan YH, Patel K, Weaver M, Sodickson A, Khurana B. Magnetic resonance imaging for acute hip pain in the emergency department. Emerg Radiol 2015; 22:409-22. [PMID: 25595215 DOI: 10.1007/s10140-014-1293-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 12/29/2014] [Indexed: 11/26/2022]
Affiliation(s)
- Sachin S Saboo
- Department of Radiology, Brigham and Women's Hospital & Harvard Medical School, Boston, MA, USA,
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48
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Balsa A, Martín-Mola E. Infectious arthritis I. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00107-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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49
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Abstract
Osteomyelitis of the foot and ankle is a common, potentially devastating condition with diagnostic and treatment challenges. Understanding the epidemiology and pathogenesis of osteomyelitis can raise clinical suspicion and guide testing and treatments. History and physical examination, laboratory studies, vascular studies, histologic and microbiologic analyses, and various imaging modalities contribute to diagnosis and treatment. Treatment including empiric broad-spectrum antibiotics and surgery should take a multidisciplinary approach to optimize patient factors, ensure eradication of the infection, and restore function. Optimization of vascular status, soft tissues, limb biomechanics, and physiologic state of the patient must be considered to accelerate and ensure healing.
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50
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Palestro CJ. Nuclear medicine and the failed joint replacement: Past, present, and future. World J Radiol 2014; 6:446-458. [PMID: 25071885 PMCID: PMC4109096 DOI: 10.4329/wjr.v6.i7.446] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 02/26/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
Soon after the introduction of the modern prosthetic joint, it was recognized that radionuclide imaging provides useful information about these devices. The bone scan was used extensively to identify causes of prosthetic joint failure. It became apparent, however, that although sensitive, regardless of how the images were analyzed or how it was performed, the test was not specific and could not distinguish among the causes of prosthetic failure. Advances in anatomic imaging, notably cross sectional modalities, have facilitated the diagnosis of many, if not most, causes of prosthetic failure, with the important exception of infection. This has led to a shift in the diagnostic paradigm, in which nuclear medicine investigations increasingly have focused on diagnosing infection. The recognition that bone scintigraphy could not reliably diagnose infection led to the development of combined studies, first bone/gallium and subsequently leukocyte/bone and leukocyte/marrow imaging. Labeled leukocyte imaging, combined with bone marrow imaging is the most accurate (about 90%) imaging test for diagnosing joint arthroplasty infection. Its value not withstanding, there are significant disadvantages to this test. In-vivo techniques for labeling leukocytes, using antigranulocyte antibodies have been explored, but have their own limitations and the results have been inconsistent. Fluorodeoxyglucose (FDG)-positron emission tomography (FDG-PET) has been extensively investigated for more than a decade but its role in diagnosing the infected prosthesis has yet to be established. Antimicrobial peptides bind to bacterial cell membranes and are infection specific. Data suggest that these agents may be useful for diagnosing prosthetic joint infection, but large scale studies have yet to be undertaken. Although for many years nuclear medicine has focused on diagnosing prosthetic joint infection, the advent of hybrid imaging with single-photon emission computed tomography(SPECT)/electronic computer X-ray tomography technique (CT) and the availability of fluorine-18 fluoride PET suggests that the diagnostic paradigm may be shifting again. By providing the anatomic information lacking in conventional radionuclide studies, there is renewed interest in bone scintigraphy, performed as a SPECT/CT procedure, for detecting joint instability, mechanical loosening and component malpositioning. Fluoride-PET may provide new insights into periprosthetic bone metabolism. The objective of this manuscript is to provide a comprehensive review of the evolution of nuclear medicine imaging of joint replacements.
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