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. 2006 Mar 3:7:20.
doi: 10.1186/1471-2474-7-20.

The implications of 18F-FDG PET for the diagnosis of endoprosthetic loosening and infection in hip and knee arthroplasty: results from a prospective, blinded study

K-St Delank  1 , M Schmidt, J W-P Michael, M Dietlein, H Schicha, P Eysel
Affiliations

The implications of 18F-FDG PET for the diagnosis of endoprosthetic loosening and infection in hip and knee arthroplasty: results from a prospective, blinded study

K-St Delank et al. BMC Musculoskelet Disord. .

Abstract

Background: The most frequent complications of joint arthroplasty are septic or aseptic loosening of endoprostheses. Preoperative differentiation is essential, since very different treatment methods result from the diagnoses. The aim of the current study was to evaluate the clinical value of 18F-Fluoro-deoxyglucose positron emission tomography (18F-FDG PET) as a diagnostic modality for inflammation and loosening in hip and knee joint prostheses.

Methods: 18F-FDG-PET examinations and multiphase bone scan were performed on hip and knee endoprostheses in 27 patients prior to revision surgical procedures planned for prosthetic loosening. Intact prostheses were found at the opposite site in some patients so that additional 9 joints could be examined with the field of view of 18F-FDG PET. Verification and valuation of the PET and scintigraphic image findings were conducted by comparing them with information combined from intraoperative findings, histopathology, and microbiological investigations.

Results: Evidence of loosening was correctly determined in 76.4% of cases using 18F-FDG-PET, and in 75% of cases using bone scan. The detection of periprosthetic inflammation using 18F-FDG-PET had a sensitivity of 100% for septic cases and of 45.5% in cases of increased abrasion and aseptic foreign-body reactions. However, reliable differentiation between abrasion-induced and bacterial-caused inflammation was not possible using 18F-FDG-PET.

Conclusion: 18F-Fluoro-deoxyglucose positron emission tomography (18F-FDG-PET) allows reliable prediction of peri-prosthetic septical inflammatory tissue reactions. Because of the high sensitivity of this method, a negative PET result in the setting of a diagnostically unclear situation eliminates the need for revision surgery. In contrast, a positive PET result gives no clear differentiation regarding the cause of inflammation.

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Figures

Figure 1
Figure 1
Qualitative visual analysis of tracer distribution according to the classification system of Reinartz et al. [11]
Figure 2
Figure 2
Intraoperatively confirmed loosening of the proximal and distal components. An infection with coagulase negative staphylococcus was also identified. PET was initially interpreted as synovialitis without signs of mechanical loosening. The inflamed synovium as well as the periprosthetic osteolytic areas (arrow) filled with bacteria-infected granulation tissue showed 18F-FDG uptake.
Figure 3
Figure 3
18F-FDG-PET showed periacetabular uptake (pattern 4a) as evidence of loosening of the cup confirmed by surgery. A bacterial infection was excluded. Loosening of the shaft within the cement bed is not adequately depicted by 18F-FDG-PET.
Figure 4
Figure 4
PET findings with reference to mechanical prosthetic loosening and inflammation.
Figure 5
Figure 5
In a case with extensive abrasion-induced inflammation on the right hip prosthesis (bacterial infection was excluded) whereas bone scan in comparison to 18F-FDG-PET does not adequately demonstrate the pathology. The PET examination shows broad periprosthetic uptake as expression of synovitis.
See this image and copyright information in PMC

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