Combined bone scintigraphy with 99mTc-MDP and 99mTc-ciprofloxacin in differentiation of hip and knee prosthesis aseptic loosening and infection: A preliminary study

Dragan Pucar; Zoran Janković; Zoran Baščarević; Srdjan Starčević; Milica Čizmić; Marija Radulović; Marija Šišić; Sanja Dugonjić; Ljiljana Jauković; Boris Ajdinović

doi:10.2298/VSP151211150P

Dragan Pucar Military Medical Academy, Institute of Nuclear Medicine, Belgrade, Serbia.
Zoran Janković Military Medical Academy, Institute of Nuclear Medicine, Belgrade, Serbia; University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia.
Zoran Baščarević University of Belgrade, Faculty of Medicine Institute for Orthopedic Surgery “Banjica”, Belgrade, Serbia
Srdjan Starčević University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia; Military Medical Academy, Clinic for Orthopedic Surgery and Traumatology, Belgrade, Serbia.
Milica Čizmić University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia; Military Medical Academy, Clinic of Endocrinology, Belgrade, Serbia.
Marija Radulović Military Medical Academy, Institute of Nuclear Medicine, Belgrade, Serbia.
Marija Šišić Military Medical Academy, Institute of Nuclear Medicine, Belgrade, Serbia.
Sanja Dugonjić Military Medical Academy, Institute of Nuclear Medicine, Belgrade, Serbia.
Ljiljana Jauković Military Medical Academy, Institute of Nuclear Medicine, Belgrade, Serbia; University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia.
Boris Ajdinović Military Medical Academy, Institute of Nuclear Medicine, Belgrade, Serbia; University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia.

DOI: https://doi.org/10.2298/VSP151211150P

Keywords: knee prosthesis, hip prosthesis, infection, diagnosis, differential, radionuclide imaging, technetium tc 99m medronate, technetium tc 99m ciprofloxacin,

Abstract

Background/Aim. Although the number of new primary implantation of hip and knee prostheses every year increases, the rate of failed arthroplasty is nearly the same. The main question is whether it is an aseptic instability or instability caused by infection. The aim of this preliminary study was an attempt with combined ^99mTc-ciprofloxacin and ^99mTc-methylene diphosphonate (MDP) bone scintigraphy to improve diagnostic accuracy in the differentiation of hip and knee prosthesis aseptic loosening and periprosthetic joint infection. Methods. Inclusion criteria of patients for this study were based on suspected periprosthetic joint infection: painful prosthetic joint, restricted joint movements and increased value of erythrocyte sedimentation rate or levels of C-reactive protein. We examined 20 patients with implanted 14 hip and 6 knee prosthesis. All patients also underwent plain radiography of suspected joint. In all patients, three-phase ^99mTc-MDP bone scintigraphy was performed. Three to five days after the bone scan, we performed scintigraphy using ^99mTc-ciprofloxacin with the calculation of accumulation index. Periprosthetic joint infection was confirmed on the basis of microbiological findings. Results. Periprosthetic joint infection was confirmed in fourteen of twenty observed joints, in five of them the aseptic loosening was present and in one patient’s symptoms were not related to the prosthesis (poor biomechanics of prosthetic joints caused by weaknesses of muscle). Estimated sensitivity/specificity for ^99mTc-MDP bone scintigraphy alone were 100/17%; for ^99mTc-ciprofloxacin scintigraphy were 85,7/100%. Sensitivity and specificity were 92,3% and 83,3%, respectively for results obtained with combined assessment by both methods. Our study confirmed the high negative predictive value of ^99mTc-MDP bone scan. The negative result of bone scan virtually excludes the possibility of periprosthetic infection. On the other hand, positive findings of ^99mTc-MDP scintigraphy cannot with certainty confirm the infection. Conclusion. Combined ^99mTc-MDP scintigraphy with ^99mTc-ciprofloxacin scintigraphy significantly increases the ability of differentiation of aseptic loosening from periprosthetic joint infection.

Author Biography

Dragan Pucar, Military Medical Academy, Institute of Nuclear Medicine, Belgrade, Serbia.

Institut za nuklearnu medicinu VMA

Načelnik Odeljenja za morfološku dijagnostiku

Potpukovnik, prim mr sc med

References

Osmon DR, Berbari EF, Berendt AR, Lew D, Zimmerli W, Steckel-berg JM, et al. Executive summary: diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2013; 56(1): 1−10.

Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of pri-mary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007; 89(4): 780−-5.

Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med 2004; 351(16): 1645−54.

Kessler B, Sendi P, Graber P, Knupp M, Zwicky L, Hintermann B, et al. Risk factors for periprosthetic ankle joint infection: A case-control study. J Bone Joint Surg Am 2012; 94(20): 1871−6.

Bongartz T, Halligan CS, Osmon DR, Reinalda MS, Bamlet WR, Crowson CS, et al. Incidence and risk factors of prosthetic joint infection after total hip or knee replacement in patients with rheumatoid arthritis. Arthritis Rheum 2008; 59(12): 1713−20.

Lentino JR. Prosthetic joint infections: bane of orthopedists, challenge for infectious disease specialists. Clin Infect Dis 2003; 36(9): 1157−61.

Tigges S, Stiles RG, Roberson JR. Complications of hip arthro-plasty causing periprosthetic radiolucency on plain radio-graphs. AJR Am J Roentgenol 1994; 162(6): 1387−91.

Dumarey N, Blocklet D, Appelboom T, Tant L, Schoutens A. Infec-ton is not specific for bacterial osteo-articular infective pathol-ogy. Eur J Nucl Med Mol Imaging 2002; 29(4): 530−5.

Sarda L, Saleh-Mghir A, Peker C, Meulemans A, Crémieux A, LeGuludec D. Evaluation of (99m)Tc-ciprofloxacin scintigraphy in a rabbit model of Staphylococcus aureus prosthetic joint in-fection. J Nucl Med 2002; 43(2): 239−45.

Pucar D. Validity of 99mTc-ciprofloxacin scintigraphy with es-timation of accumulation index in diagnostic of bone infection [thesis]. Belgrade: Military Medical Academy; 2006. (Serbian)

Pucar D, Janković Z, Dugonjić S, Popović Z. Estimation of 99mTc-ciprofloxacin accumulation indexes in bone and joint bacterial infections. Vojnosanit Pregl 2009; 66(5): 395−8.

Truluck CA. Nuclear medicine technology: Inflammation and infection imaging. J Radiol Nurs 2007; 26(3): 77−85.

Nagoya S, Kaya M, Sasaki M, Tateda K, Yamashita T. Diagnosis of peri-prosthetic infection at the hip using triplephase bone scintigraphy. J Bone Joint Surg 2008; 90(2): 140−4.

Reinartz P, Mumme T, Hermanns B, Cremerius U, Wirtz DC, Schaefer WM, at al. Radionuclide imaging of the painful hip arthro-plasty: Positron-emission tomography versus triple-phase bone scanning. J Bone Joint Surg 2005; 87(4): 465−70.

Stumpe KD, Nötzli HP, Zanetti M, Kamel EM, Hany TF, Görres GW, et al. FDG PET for differentiation of infection and asep-tic loosening in total hip replacements: Comparison with con-ventional radiography and three-phase bone scintigraphy. Ra-diology 2004; 231(2): 333−41.

Palestro CJ. Nuclear medicine and the failed joint replacement: Past, present, and future. World J Radiol 2014; 6(7): 446−58.

Love C, Marwin SE, Palestro CJ. Nuclear medicine and the in-fected joint replacement. Semin Nucl Med 2009; 39(1): 66−78.

Vinjamuri S, Hall AV, Solanki KK, Bomanji J, Siraj Q, O'Shaugh-nessy OE, et al. Comparison of 99mTc infecton imaging with radiolabelled white-cell imaging in the evaluation of bacterial infection. Lancet 1996; 347(8996): 233−5.

Britton KE, Wareham DW, Das SS, Solanki KK, Amaral H, Bhat-nagar A, et al. Imaging bacterial infection with (99m)Tc-ciprofloxacin (Infecton). J Clin Pathol 2002; 55(11): 817−23.

Sarda L, Crémieux A, Lebellec Y, Meulemans A, Lebtahi R, Hayem G, et al. Inability of 99mTc-ciprofloxacin scintigraphy to dis-criminate between septic and sterile osteoarticular diseases. J Nucl Med 2003; 44(6): 920−6.