They are usually 2 mm or less; Lucencies greater than 2 mm can indicate loosening or infection or particle disease, or all three Typical appearance shows loosening on bone scan: Increased uptake in region of greater and lesser trochanters and at tip of the prosthesis. A 99m Tc-HDP bone SPECT/CT was instrumental in accurately defining the focal point of excessive bony stress as well as in defining the impression fracture and prosthetic loosening. Aseptic Loosening. Nuclear medicine and the failed joint replacement: Past Tc-99m albumin or sulfur colloid is taken up by the reticuloendothelial cells present in bone marrow and is the basis for this imaging procedure. Diffuse uptake may be present in complex regional pain syndrome (CRPS). Nuclear medicine and the failed joint replacement: Past Bone scans image both the structure, and the active cell growth of the bones, and are often used in conjunction with other imaging e.g. Note that there are no regions of lucency around the new prosthesis. A radioactive material (radiopharmaceutical) is injected into a vein, attaches to the bones and is detected by a special camera (gamma camera) that takes images or pictures that show how the bones are working. depiction of soft tissue and bone around the prosthesis. We evaluated 28 patients with complicated UHPs who had undergone total hip arthroplasty a very long time previously (range 3-20 years, mean 8.4). Some radiological features are pathognomonic of bone and joint infections for each modality used. Aseptic loosening of a cemented implant most likely indicates failure by shear or tension of the bone-bone cement interface, or failure after the generation of wear debris, together with lubrication effects within the joint, causing osteolysis. Especially if more zones are involved and if there is progression. This case report describes the use of the 99mTolabeled radiopharmaceutical eiprofloxaein (Infecton) in a case of hip prosthesis loosening in a dog. Leucocyte uptake around a prosthesis may reflect bone marrow displacement or surgical activation. Always compare the SPECT-CT with a baseline plain film from surgery. By 10 years after implantation, rough- ly half of all prostheses exhibit radio-graphic evidence of loosening and up to 30% require revision. Features are consistent with loosening. Three Phase Bone/ 111IN Scan a.) 6 weeks postoperatively. PDF Evaluation of Infection/Inflammation: What is the Role of 5 A synovial-like pseudomembranous structure develops. Gallium imaging is often performed to enhance the specificity of bone scintigraphy. Three years following the revision, the patient presented again with persistent pain in the prosthetic right-knee joint. Prosthesis Loosening - an overview | ScienceDirect Topics . PDF W J R World Journal of Radiology Nuclear Medicine Bone Scan - InsideRadiology Tc-sulesomab (trade name LeukoScan): in vivo labelled Fab fragment of IgG1. Evaluation for infection:-Indium WBC scan (leukocytes), and Sulfur colloid (evaluate marrow).-If there is an infection aorta has a mismatch (low on sulfur colloid and bright on WBC scan). This new prosthesis reverses the normal ball-and-socket relationship of the shoulder joint. Increased uptake can be seen up to 1 year. 7). Therefore, LS has been combined with 99mTc-sulphur colloid. There are stud-ies documenting 18F-FDG accumulation in prosthesis loos-ening (36-39). Prosthetic loosening with orwithout infection was the most common etiology, accounting for 27%ofthisgroup(W.R.Murray, unpublished data).Other sources ofpain inthepostoperative patient include hag-mentous instability, fractures, referred pain, prosthetic fail-ure,andunknown causes [2,5,10].Thehighincidence of Bone scan Gallium scan WBC imaging FDG-PET Morphologic Functional . However, imaging diagnosis of these infections is challenging because of several overlaps with non-infectious etiologies. Criteria for loosening depends on site and make of prosthesis. : Nuclear medicine scans may be ordered 1 year postoperatively but may have positive findings that are due to normal physiologic bone remodeling. The toggle sign is indicative of prosthetic loosening and refers to a hot spot at the tip of a prosthesis and two areas of increased uptake at the proximal end, like a toggle switch. 1 case question available Before and 1 year after the operation, and at fol- The blood flow and blood pool images were normal. As a result of replacement of the glenoid component with a ball and of the humeral head with a socket, the center of rotation is moved distally and medially, allowing more control of shoulder motion by the . 1976). The 3-phase bone scan consists of a 1-minute radionuclide angiogram followed by immediate blood pool images and 2- to 3-hour delayed views. Only activity at the bone-prosthesis interface (femoral or tibial components), regardless of intensity " Positive criterion 4: ! Aseptic loosening is physical movement of the prosthesis and is due to a number of causes. The There is a lucent zone of more than 2 mm at the bone-prosthesis interface, there is also cranial migration of the prosthesis. Reciprocal changes in sensitivity and specificity with increasingly stringent criteria were shown. Bone Scans are performed for many reasons including, but not limited to, looking for fractures, metastasis, infection, prosthesis loosening, and necrosis. In patients lacking PJI, the bone marrow distributions evident on LS and bone marrow scans are similar. Femoral component loosening demonstrated on bone scan. These prostheses are anchored to bone by various methods including polymethylmethacrylate and osseous ingrowth into the device's surface. Triple phase Tc99m bone scan and Indium leukocyte scanning have important role in differentaiting between infected andaseptic loosening. A lucent zone Component migration is diagnostic for loosening. The overall clinical outcome was better in cementless than in cemented prostheses. Full maturation of hetero-topic bone takes up to 1 year (Figure 6). Thereafter, increased labeling correlates with infection, loosening, and heterotopic bone formation, depending upon the pattern of localization. Left: 2D FSE (0.7 x 1.0 mm, scan time: 6:08 min) images of a right MOM total hip arthroplasty. While this also binds to neutrophils (5%) and therefore should mimic WBC labelled scans it has a non-specific accumulation at infected sites. Increased bone turnover can be detected as early as 1 week after surgery, with excessive increases in the spe-cific osteoclastic and osteoblastic markers (CTX-1 and P1NP) detected in venous blood. In a manner analogous to bone/gallium imaging, it has been suggested that interpreting WBC images together with bone scans improves results. Normal lucency is < 2mm at cement-bone interface; Lucencies at metal-cement interface or metal-bone interface may be secondary to surgery and should remain unchanged over time. Imaging Findings. aseptic loosening of the prosthesis implant. Antibiotic treatment did not result in improvement of the lameness. Semi-quantitative analysis of FDG uptake at the bone-prosthesis interface Love et al. Despite these limitations, radiography serves as a reference to monitor the progression of bone abnormalities. Imaging is an important aspect of the identification and management of loosening of total knee replacement prosthesis. NUCLEAR TRACERS used in imaging prosthetic joints. The patient subsequently received a revision total knee arthroplasty (TKA). Kumar et al found that dual phase 18F fluoride PET/CT has considerable potential in differentiating septic and aseptic loosening of hip prostheses. Download as PDF. Bright MDP scan. 3,4 In many cases, loosening results from an inflammatory or immune reaction. Plain radiographic findings may be nonspecific. Lucency treated as prosthetic loosening and a revision has been performed. 2D PD FSE (MARS) MAVRIC SL MAVRIC SL at 3T Courtesy of Hospital for Special Surgery, New York MAVRIC SL in the Hip at 3T OBJECTIVE.The purposes of this article are to review current concepts of knee replacement, including features of traditional and newer prosthetic designs, materials, and surgical techniques; illustrate normal and abnormal postoperative imaging findings; and to relate the complications to current understanding of how and why these failures occur. A 3-phase bone scan is a powerful tool within the nuclear medicine diagnostic toolkit. Scintigraphy was performed with 99mTcInfecton, a tracer claimed to be specific . Imaging is an important aspect of the identification and management of loosening of total knee replacement prosthesis. corresponding uptake on SC scan " Positive criterion 3: ! The three-phase bone scintigraphy pattern of loosening in uncemented hip prostheses (UHPs) has not previously been elucidated. Failure of Initial Component . It became apparent, however, that . The remaining bone scan indications are imaged primarily utilizing a single, delayed-phase-only protocol. A positive technetium-labeled bone scan is extremely sensitive for detecting bone remodeling changes around prosthetic joints and can indicate loosening, infection, or stress fracture. bone only (cranial to the prosthesis) and 3 slices that contained bone and prosthetic cup (cranial to the prosthetic femoral head) were selected. They are often used as a follow-up test when the cause of your pain or symptoms needs to be clarified, for example: A nuclear medicine bone scan also shows whether there has been any improvement or deterioration in a bone abnormality after treatment. Osteomyelitis/Infection vs. LOOSENING 6. Evaluation of prosthesis for loosening or infection. Prosthesis loosening Nuclear imaging findings: Diffuse periprosthetic uptake of tracer on skeletal scintigraphy suggest osteolysis from loosening or infection. Sulfur colloid used to evaluate bone marrow. On plain radiographs prosthetic loosening can frequently be recognised by the occurrence of progressive radiolucency in the bone-prosthesis interface or by migration of the implant. CT scan evaluation of glenoid bone and pectoralis major tendon: interest in shoulder prosthesis Laurent Obert1,2,*, Christelle Peyron2,3, Etienne Boyer1, Gauthier Menu1, Franois Loisel1,2 and Sbastien Aubry2,3 1 Orthopaedic and Traumatology Surgery Service, University Hospital of Besanon, 25000 Besanon, France 2 Intervention, Innovation, Imagery, Engineering in Health (EA 4268 . The three-phase bone scintigraphy pattern of loosening in uncemented hip prostheses (UHPs) has not previously been elucidated. reported that 20% of radiographs showed bone findings consistent with infection, 20% had signs of mechanical loosening and 10% had nonspecific findings . Assessment . Imaging prosthetic joints in nuclear medicine involves using several different radiotracers. The standard single-phase bone scan involves imaging 2 to 3 hours after MDP administration. The cause is usually haematogenous seeding associated with a distant infection.The diagnostic work-up for infection includes ESR and CRP and joint aspiration for suspected infection. Especially plain radiographs often show signs of loosening only after a long delay of time. Progressive changes are more significant. Normal lucency is < 2mm at cement-bone interface; Lucencies at metal-cement interface or metal-bone interface may be secondary to surgery and should remain unchanged over time. They are usually 2 mm or less; Lucencies greater than 2 mm can indicate loosening or infection or particle disease, or all three 13 of the ultimately identified 18 reasons for hip pain were diagnosed by Hybrid SPECT/CT imaging: prosthetic loosening (n = 6), heterotopic ossification (n = 5), lumbar spinal stenosis with facet joint arthrosis (n = 1) and a periprosthetic stress fracture (n = 1). The purpose of this study is to evaluate the relationship between radiolucency, pain, loosen- ing, and bone scan results. . Bone Scans 14 prosthetic hips 6 cementless femoral components All fixed 8 cemented femoral components 6 fixed 2 losening at cement-prosthesis interface 1 prosthetic knee Cemented Loosening at cement-prosthesis interface . Bloodpool phase imaging is commonly performed as part of a bone scintigram , particularly when we are interested in evaluating prostheses for infection or loosening. From: Orthopaedic Bone Cements, 2008. Preliminary data suggests . One case of loosening was caused by a periprosthetic infection. Right: MAVRIC SL of the same patient (1.3 x 1.6 mm, scan time: 5:37 min) demonstrates femoral osteolysis (arrow). F18-fluoride-PET (fluoride-PET) bone imaging is an evolving technique that has demonstrated good results in a few studies. JNM. Imaging Findings. Start studying Bone Imaging + Pathologies. Aseptic loosening was confirmed using 3 phase bone scan in hips having clinical pain or signs of loosening in the radiographs. Any patients who had trochanteric osteotomy, bone grafting of the femur or the acetabulum, an active infection at any site, abnormal laboratory findings (C-reactive protein > 1.0 mg/dL; erythrocyte sedimentation rate > 30 mm/hour), inflammation, or other diseases in the sacroiliac joints, any signs of loosening as shown by plain radiographs, or breakage of the prosthesis 5,6,13 were excluded. Location of biopsy site. The blood pool phase typically follows the dynamic or vascular phase imaging as part of the three phase bone scan. scan (Figure 1), which suggested loosening of the tibial component. Especially plain radiographs often show signs of loosening only after a long delay of time. Van Acker et al. In one study, WBC imaging alone was 45% specic for prosthetic joint infection, but improved to 85% with the addition of bone imaging[ 44 ]. The Teaching Point: Particle disease, an asymptomatic illness that will lead to aseptic loosening, can be differentiated from metastasis, infection, or non-infectious etiology by 3-phase bone scan and 18F-Fluoride PET/CT. All the patients were surgi Ultrasound and MRI are useful for assessing soft tissue collections. load, fatigue failure at the bone prosthesis or cement-pros-thesisinterface,implantmotion,andhydrodynamicpressure aresometimesresponsible,themostfrequentcauseofaseptic loosening is an inammatory reaction to one or more of the prosthetic components.5 Particulate debris, produced by component fragmentation, presumably attracts and activates Prosthesis Loosening. Skeletal scintigraphy is nonspecific for differentiating prosthesis loosening and infection. In many cases, especially in early stages of loosening, the radiographs are indeterminate or even false negative. While it is apparent that the bone scan cannot be used as the sole diagnostic method for evaluation of prosthetic stability, it does seem to be useful adjunct along with clinical criteria and radiographic studies. This exam may be called - Bone Scan, Whole Body (WB), Total Body (TB), Limited (LTD), 3-Phase or Triple-Phase Bone Scan, Bone SPECT. 6. A lucent zone of more than 2 mm at the bone-prosthesis interface or at the bone-cement interface is very indicative of loosening. Bone scan can be positive as early as 3 weeks. - Imaging - Plain x-ray not useful for diagnosis of early infection but may identify loosening of prosthesis or osteolysis. Complications of hip and knee prostheses such as periprosthetic fracture, infection and loosening - all of which present with a painful prosthesis - may be distinguished with bone scan by their characteristic appearances. Increased uptake can be seen up to 1 year. Serial planar radiographs were not conclusive, and culture of the synovial fluid was negative. - In many cases, loosening is first evidenced on nuclear scintigraphy by increased activity at the tip of the prosthesis, 1 year after placement. The reverse shoulder prosthesis was approved for clinical use in the United States in March 2004. Uptake of gallium is related to inflammation in general and not to infection specifically. Triple phase Tc99m bone scan and Indium leukocyte scanning have important role in differentaiting between infected andaseptic loosening. The tracers discussed in this article are: Tc-MDP: bone scintigraphy Tc-sulesomab: in vivo labelled Fab fragment of IgG1. Skeletal scintigraphy is nonspecific for differentiating prosthesis loosening and infection. We evaluated 28 patients with complicated UHPs who had undergone total. X-rays, computed tomography (CT) or magnetic resonance imaging (MRI). A 76-y-old man with painful unilateral right knee prosthesis and signs of loosening on plain radiograph. Poor initial positioning of the prosthesis, Material failure of the prosthesis, Reaction between the bone and a component of the prosthesis causing osteolysis of bone. - w/ lack of ingrowth, bone scan would show modest uptake around loose femoral component, however, mild uptake can be expected at the tip of stable components; - Bone Scan for THR: - although bone scans may help, many noncemented THR, esp long stems, may show some increase in activity - loosening (most common) - fracture - arthritis - osteomyelitis - trauma The aims of this study were: (1) to describe the patterns of a normal and a pathologic bone scan; and (2) to exemplify ten common situations that can cause painful hip or knee prosthesis, other than loosening and infection, and that can be found on bone scan. . The cellular response is characterized by an influx of vari-ous types of leukocytes. . Nuclear medicine techniques can be helpful in this differentiation: a normal bone scan virtually excludes loosening, and combined imaging of bone marrow and 111In-labeled white blood cells is the . 35% of activity at 24hrs is in the bone . The rest of this article focuses primarily on the single-phase bone scan. 3-Phase or Triple Phase: Injection with immediate images requiring approximately 20 [] When calculat- Todays standard diagnostic procedures for ruling out prosthetic loosening most often include x-ray and bone scan imaging, as well as joint punctures and laboratory tests which feature wide ranges in specificity and sensitivity . The wider and more extensive the periprosthetic lucency is, the higher the chance of loosening. On F-18 PET/CT, particle disease shows up as a well-defined, intense uptake surrounding an erosive lesion of bone with the lesion tracking along the screw. 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