Nuclear medicine imaging of posttraumatic osteomyelitis

Abstract

Introduction: Early recognition of a possible infection and therefore a prompt and accurate diagnostic strategy is essential for a successful treatment of posttraumatic osteomyelitis (PTO). However, at this moment there is no single routine test available that can detect osteomyelitis beyond doubt and the performed diagnostic tests mostly depend on personal experience, available techniques and financial aspects. Nuclear medicine techniques focus on imaging pathophysiological changes which usually precede anatomical changes. Together with recent development in hybrid camera systems, leading to better spatial resolution and quantification possibilities, this provides new opportunities and possibilities for nuclear medicine modalities to play an important role in diagnosing PTO.

Aim: In this overview paper the techniques and available literature results for PTO are discussed for the three most commonly used nuclear medicine techniques: the three phase bone scan (with SPECT-CT), white blood cell scintigraphy (also called leukocyte scan) with SPECT-CT and (18)F-fluorodeoxyglucose (FDG)-PET/CT. Emphasis is on how these techniques are able to answer the diagnostic questions from the clinicians (trauma and orthopaedic surgeons) and which technique should be used to answer a specific question. Furthermore, three illustrative cases from clinical practice are described.

Keywords: Bone scan; FDG-PET; Nuclear medicine; Posttraumatic osteomyelitis; White blood cell scan.

Fig. 1

Left image gamma camera with SPECT-CT possibility (Siemens Symbia T). Right PET-CT camera (Siemens Biograph mCT 64-slice). Image courtesy: Siemens Medical Systems, Knoxville, TN

Fig. 2

Example of a normal three-phase bone scan in a patient with pain complaints of the lumbar spine. Upper row images: flow/perfusion images (phase 1). Lower row, left image blood pool image (phase 2). Lower row, middle image (anterior view, phase 3), right image (posterior view, phase 3)

Fig. 3

Example of a positive WBC scintigraphy of a 39 years old patient with osteomyelitis of the right tibia. Left image anterior view 4 h after injection. Right image anterior view 24 h after injection. Increase in uptake in time, especially when the background uptake is taking into account: suspect for an infection

Fig. 4

Patient with a proven tuberculosis osteomyelitis of the left shoulder. FDG-PET was performed to identify any disseminated foci of infection. FDG-PET image (left) and fusion PET-CT image (right) showing multiple infectious foci in the body (left shoulder, multiple vertebras, right upper arm, left upper leg)

Fig. 5

WBC scan (a–d images after 4 h, e–f images after 24 h) and late phase bone scan (g anterior view, h lateral view) of patient A

Fig. 6

WBC scan SPECT-CT of patient A

Fig. 7

X-ray (left image) and bone scan (upper row flow phase, middle image lower row blood pool phase, right image lower row SPECT-CT late phase) of patient B

Fig. 8

WBC scan (upper row images after 4 h, lower row images after 24 h) of patient B

Fig. 9

WBC scan (left image anterior view after 4 h, right image: anterior view after 24 h) of patient C

Fig. 10

WBC SPECT-CT of patient C