Can99mTc-MDP-SPECT/CT Differentiate Loosening and Infection After Hip and Knee Replacements?

Abstract

Background: Prosthetic loosening and infection are still common complications after joint replacement. Over the past few years, single-photon emission computed tomography-computed tomography (SPECT/CT) was widely used and showed unique value based on the combination of anatomic and metabolic information of foci. However, its performance in differentiating between prosthetic loosening and periprosthetic infection after joint replacement is still the focus of clinicians and deserves further investigation.

Purpose: This retrospective study was aimed to determine whether bone scintigraphy combined with SPECT/CT still can differentiate prosthetic infection from loosening in patients after joint replacement. The differential efficacy in hip and knee prosthesis was also analyzed. Blood biomarkers for the diagnosis of periprosthetic infection were also evaluated.

Patients and methods: Data sets of 74 prosthetic joints (including knees and hips), with suspected prosthetic loosening or infection between 2015 and 2021, were evaluated. Besides the results of nuclear imaging, X-ray images and serum biomarker were also recorded. Telephone follow-up and revision surgery after SPECT/CT were used as a gold standard. The sensitivity and accuracy of different imaging modalities were calculated by Chi-square test. The diagnostic efficacy of imaging methods and serum biomarkers were then analyzed by the area under curve (receiver operating characteristic curves, ROC) in SPSS 26.

Results: In all, 47 joints (14 knees and 33 hips) were confirmed as aseptic loosening, while 25 joints (18 knees and 7 hips) were confirmed as infection. The sensitivity and accuracy of SPECT combined with SPECT/CT imaging were the highest (92.86% and 87.84%, respectively). The differential efficacy of bone scintigraphy combined with SPECT/CT imaging was also better than any other single imaging modality. In the analysis of involved prosthesis, prosthetic loosening occurred more in hip prosthesis and knee prosthesis was easily infected (P < 0.05). Finally, the sensitivity of ESR and CRP were 80% and 84%, respectively.

Conclusions: Bone scintigraphy with hybrid SPECT/CT remains encouraging in differentiating prosthetic infection from loosening after joint replacement. The diagnostic efficacy of differentiation in hip prosthesis was better than knee. Serum biomarkers cannot be used alone to differentiate prosthetic infection from loosening.

Keywords: 99mTc-MDP–SPECT/CT; Differentiate; Infection; Loosening; Prosthesis.

Fig. 1

Flow chart for methodology

Fig. 2

Typical cases of prosthetic loosening and infection. a Bone scintigraphy of prosthesis loosening in the right hip. An abnormal uptake at right femur stem was shown. a1–a4 showed the foci SPECT/CT images in coronal view (a1 and a2) and transverse view (a3 and a4). Higher uptakes were shown at stress sites. b Bone scintigraphy of periprosthetic infection in the left knee. Diffused concentration at left upper tibia was shown; b1–b4 showed diffused uptake around tibia prothesis

Fig. 3

Typical images of false-positive and false-negative cases. a False-positive case with diffused concentration at left knee in bone scintigraphy. a1–a4 inferred the concentration aiming at stress sites. b False-negative case with higher uptake at left knee in bone scintigraphy. b1–b4 showed the tomography images of region of interest (ROI). In addition, clinical history infers that this patient took antibiotics before bone scan

Fig. 4

ROC curve of several imaging modalities for the diagnosis of prosthetic loosening

Fig. 5

ROC curve of different imaging modalities for the diagnosis of periprosthetic infection

Fig. 6

ROC curve of blood markers: ESR and CRP for diagnosing periprosthetic infection