Aim. White blood cell (WBC) scintigraphy for diagnosing fracture-related infections (FRIs) has only been investigated in small patient series. Aims of this study were (1) to establish the accuracy of WBC scintigraphy for diagnosing FRIs, and (2) to investigate whether the duration of the time interval between surgery and WBC scintigraphy influences its accuracy. Method. 192 consecutive WBC scintigraphies with . 99m. Tc-HMPAO-labelled autologous leucocytes performed for suspected peripheral FRI were included. The goldstandard was based on the outcome of microbiological investigation in case of surgery, or - when these were not available - on clinical follow-up of at least six months. The discriminative ability of the imaging modalities was quantified by several measures of diagnostic accuracy. A multivariable logistic regression analysis was performed to identify predictive variables of a false-positive or false-negative WBC scintigraphy test result. Results. WBC scintigraphy had a sensitivity of 0.79, a specificity of 0.97, a positive predicting value of 0.91, a negative predicting value of 0.93 and a diagnostic accuracy of 0.92 for detecting an FRI in the peripheral skeleton. The duration of the interval between surgery and the WBC scintigraphy did not influence its diagnostic accuracy; neither did concomitant use of antibiotics or NSAIDs. There were 11 patients with a false-negative (FN) WBC scintigraphy, the majority of these patients (n = 9, 82%) suffered from an infected nonunion. Four patients had a false-positive (FP) WBC scintigraphy. Conclusions. WBC scintigraphy showed a high diagnostic accuracy (0.92) for detecting FRIs in the peripheral skeleton. Duration of the time interval between surgery for the initial injury and the WBC did not influence the results which indicate that WBC scintigraphy is accurate shortly after surgery

Tc 99m labelled leukocytes scintigraphy (LLS) could be useful for the diagnosis of bone and joint infections. The aim of our study was to evaluate its performances specifically in the diagnosis of prosthetic joint infection (PJI). We conducted a multicenter -7 year- retrospective study including 164 patients with suspected PJI who underwent surgical treatment. In each case, 5 intraoperative samples were taken. Diagnosis of infection was confirmed if two or more samples yielded the same microbial agent. LLS was considered as « positive » if an accumulation of leukocytes was observed in early stage and increased in late stage (24 hours). Among these patients, 123 had also a bone scintigraphy. A total of 168 PJ were analyzed: 150 by in vitro polymorphonuclear labelled leukocytes scintigraphy (PLLS) and 18 by anti-granulocytes antibodies labelled leukocytes scintigraphy (LeukoScan®). Location of PJ were: hip (n = 63), knee (n = 71), miscellaneous (n = 4). According to microbiological criteria 62 hip prosthesis and 48 knee prosthesis were considered as infected. Sensitivity (Se), Specificity (Sp), Positive Predictive Value (PPV) and Negative Predictive Value of PLLS were: 72%, 60%, 80% and 47%. Se of LLS was higher for knee PJI (87%) than for hip PJI (57%) [p = 0.002]. Although Sp was higher for hip PJI (75%) than for knee PJI (52%) [p = 0.002]. The lowest Se was found for coagulase negative staphylococci (70%) and the highest for streptococci (87.5%). However the difference of Se between bacteria was not significant. Regarding bone scintigraphy, Se, Sp, PPV and NPV were: 94%, 11%, 65% and 50%. In our study, performances of LLS were rather low and varied according to the location of infection. Differences of LLS Se between bacteria was not significant. Bone scintigraphy has a high Se but lacks Sp

We report the largest multicentre series analysing the use of bone scans investigating painful post-operative Total Knee Replacements (TKR). We questioned the usefulness of reported scintigraphic abnormalities, and how often this changed subsequent management. 127 three-phase bone-scans were performed during a two-year period. Early and late flow phases were objectively classified. Reported incidences of infection and loosening were determined. Reports were subjectively summarised and objectively analysed to establish the usefulness of this investigation. Eight cases were excluded.

Scans were classified as: 33% (39) normal, 53% (63) as possibly abnormal, 6% (7) probably abnormal, and 8% (10) as definitely abnormal. Thirteen patients (11%) underwent revision TKR surgery. Intra-operative analysis revealed loosening of one femoral component, and massive metallosis of the patella in another. Cultures were negative in all cases. The sensitivity and specificity of a definitely abnormal investigation in predicting need for revision surgery was 23% and 82% (respectively). High instances of ambiguously reported abnormalities were observed.

This investigation has no role to play in the routine investigation of a painful TKR. It is unnecessary in investigation of periprosthetic infection and should not be used in a routine assessment of a painful TKR. If used it should be limited until an experienced revision surgeon has made a full assessment.

Aim. Diagnosing Fracture-Related Infections (FRI) is challenging. White blood cell (WBC) scintigraphy is considered the best nuclear imaging technique to diagnose FRI; a recent study by our group found a diagnostic accuracy of 92%. However, many centers use . 18. F-fluorodeoxyglucose positron emission tomography/computed tomography (. 18. F-FDG-PET/CT) which has several logistic advantages. Whether . 18. F-FDG-PET/CT has better diagnostic performance than white blood cell (WBC) scintigraphy is uncertain. Therefore, we aimed: 1) to determine the diagnostic performance of . 18. F-FDG-PET/CT for diagnosing FRI (defined as infection following an open fracture or fracture surgery) and 2) to determine cut-off values of standardized uptake values (SUV) that result in optimal diagnostic performance. Method. This retrospective cohort study included all consecutive patients who received . 18. F-FDG-PET/CT to diagnose FRI in two level 1 trauma centers. Baseline demographic- and surgical characteristics were retrospectively reviewed. The reference standard consisted of at least 2 representative microbiological culture results or the presence or absence of clinical confirmatory FRI signs in at least 6 months of clinical follow-up. A nuclear medicine specialist, blinded to the reference standard, re-reviewed all scans. Additionally, SUVs were measured using the “European Association of Nuclear Medicine Research Ltd. (EARL)” reconstructed . 18. F-FDG-PET/CT scans. Volume of interests were drawn around the suspected- and corresponding contralateral area to obtain the absolute values (SUVmax) and the ratio between suspected and contralateral area (SUVratio). Diagnostic accuracy of the re-reviewed scans was calculated (sensitivity and specificity). Additionally, diagnostic characteristics of the SUV measurements were plotted in the area under the receiver operating characteristics curve (AUROC). The sensitivity and specificity at the optimal threshold was deducted from the AUROC with the Q-point method. Results. 158 . 18. F-FDG-PET/CTs were included. Mean age was 46.2 years, 71.5% was male. Most cases (56.3%) were tibial shaft- or ankle fractures. Sixty patients (38.0%) had FRI. The sensitivity and specificity of the FDG-PET/CT scan was 70.0% (95% CI 56.8–81.2) and 79.6% (95% CI 70.3–87.1) respectively. Diagnostic accuracy was 76.0% (95% CI 68.5–82.4). AUROCs of SUVmax and SUVratio were 0.80 (95% CI 0.73–0.87) and 0.73 (95% CI 0.64–0.81), respectively. The optimal SUVmax threshold of 4.2 resulted in 80.0% sensitivity and 71.3% specificity, while an SUVratio of 2.9 resulted in 58.3% sensitivity and 80.9% specificity. Conclusions. The . 18. F-FDG-PET/CT has a sensitivity of 70.0%, specificity of 79.6% and a diagnostic accuracy of 76.0%. This makes . 18. F-FDG-PET/CT less accurate than WBC scintigraphy in diagnosing FRI, although adding SUV measurements may possibly increase its diagnostic accuracy

Background and objectives. Positron emission tomography (PET) is a technology widely used in oncology. It is now being increasingly used in orthopaedics, especially in diagnosing bone infection. Diagnosis of bone infection is still a challenge, especially after surgery. Bone scintigraphy, Gallium-67 scintigraphy, and radiolabelled leucocyte scintigraphy are not specific. MRI has problems with definition in the presence of metal. PET uses 18-F Fluoro deoxyglucose(FDG) as a radiotracer. Inflammatory cells use glucose for energy, and the 18F-Fluoride component of FDG is a positron-emitting radionucleotide. We undertook this study to show our experience with the FDG-PET –CT in diagnosing bone infection and to highlight its superiority in diagnosing infected spine implants. Material and Methods. Medical records of orthopaedic patients referred to the nuclear medicine department in our hospital were retrospective reviewed. We looked at the clinical records, radiographs, bone scintigraphs, MRI and FDG-PET, assessing their diagnostic accuracy, and their value in helping the surgeon plan treatment. Results. There were 37 patients referred for possible diagnosis of bone infection. 14 had proven spine infection on FDG-PET scan. 5 of these had infected spine implants. The FDG-PET scan showed better definition of the anatomical site of the infection, allowing the surgeon to plan surgery better. Also it was not affected by presence of implants. Conclusion. FDG-PET-CT is the modality of choice for diagnosing bone infection. It is particularly useful in defining the anatomical site of the infection, especially in irregular bones, like the vertebrae. NO DISCLOSURES

Background. Periprostetic joint infections (PJI) are often difficult to diagnose, to treat and often leave the patient with severe impaired function. The presence of low virulent bacteria is frequently discovered in apparent aseptic revisions of shoulder arthroplasties and pose a challenge to diagnose preoperatively. Dual Isotope In111 Leucocyte/ Tc99 Bone Marrow SPECT CT scan (L/BMS) is considered the radionuclide gold standard in preoperative diagnosing PJI with reported high specificity and sensitivity in hip and knee arthroplasties. Unfortunately, it is labour-intensive and expensive to perform and documentation using L/BMS on shoulder arthroplasties lack. Aim. To investigate if L/BMS succeeds in detecting shoulder PJI compared to tissue cultures obtained perioperatively. Method. All patients referred to a highly-specialised shoulder department with a painful or stiff shoulder-arthroplasty were included in the cohort. To diagnose infection as a possible cause of arthroplasty failure a L/BMS was planned for all patients. If the arthroplasty was revised, 5 tissue biopsies were obtained from the most infection-suspicious site during revision. Biopsies were cultured in broth and on plates for 14 days due to the high frequency of low virulent infection in shoulder revisions. Infection was defined as growth of the same bacteria in 3 or more of 5 the biopsies. Results. During the observation period 71 patients were referred. Revision surgery was performed in 62% of the patients (44/71) of which 29 also had been examined by L/BMS. A microbiological diagnose was available for all. The most predominant organism isolated was P. Acnes. Two patients both had a positive L/BMS and positive cultures. Negative L/BMS and negative cultures were found in 20 patients. The remaining 7 patients had negative L/BMS, but positive cultures. The two patients with a positive L/BMS both showed overt clinical signs of infection. L/BMS show a sensitivity 0.22 95%CI(0–0.49) and specificity 1.00 95%CI(1.00–1.00) in detecting shoulder PJI. The Positive Predictive Value is 1.00 95%CI(1.00–1.00) and Negative Predictive Value 0.74 95%CI(0.57–0.90). No patients infected with P. Acnes resulted in a positive scintigraphy nor had they preoperative or perioperative signs of infection. Conclusion. Only patients with severe infectious symptoms of shoulder PJI resulted in positive L/BMS. Hence, the scan added nothing to the preoperative clinical diagnose. In111 Leucocyte/ Tc99 Bone Marrow SPECT CT scan cannot be recommended as a standard screening procedure when evaluating failed shoulder arthroplasties for possible infection

Aims

Chronic osteomyelitis (COM) of the lower limb in adults can be surgically managed by either limb reconstruction or amputation. This scoping review aims to map the outcomes used in studies surgically managing COM in order to aid future development of a core outcome set.

Among the extra pulmonary forms of tuberculosis (TB), the osteoarticular localization has been detached in 1–2% of cases. In 30% of these children either a pulmonary and extra-pulmonary localization was found. The diagnosis of skeletal TB is often insidious due to variable signs and symptoms. The medical records of children admitted to our center between 2006 and 2013 due to skeletal TB were evaluated. All patient underwent TB skin test, IGRA test, chest X-ray and focused imaging tests. In the complicated forms of osteoarthritis the infected material drained spontaneously or surgically was analyzed for Mycobacterium Tuberculosis (MT) detection and culture. In patients with pulmonary localization gastric aspirates or sputum analysis was performed. Nine patients met the inclusion criteria. The median age at diagnosis was 7 (range 2–13) years. All patients presented with local osteoarticular symptoms and 4 of them had fever. In five cases there was a preceding history of minor trauma. Three patients had a case of TB in the family. Four patients had a spinal localization, three hips and two ankles. ERS and CRP values were altered in 7 and 4 patients respectively. All patient underwent radiography, bone three phase scintigraphy and a MRI. The diagnosis of tuberculosis was confirmed by histopathological examination of bone biopsy in 6 (66%) cases. The skin test and the IGRA test were positive in all patients. The chest X-ray showed a pulmonary localization in 3 cases that had positive gastric aspirate or sputum. All patients were treated with isoniazid, rifampicin pyrazinamide and ethambutol. In 3 patients Linezolid or Ciprofloxacin was also associated. The follow-up had an average value of 34 months. Sequelae were reported in 7 patients (limping in 5 cases, severe kyphosis in 2 cases). Owing to its low incidence in developed countries, the diagnosis ot TB is often delayed for months to years. Additionally, we highly recommend taking a biopsy of the site of suspected infection because an early diagnosis is the key to successful treatment

In acute haematogenous multifocal osteomyelitis, infectious foci occur in several bones simultaneously due to haematogenous bacterial spread. Acute haematogenous multifocal osteomyelitis should be distinguished from chronic recurrent multifocal osteomyelitis (CRMO). We reviewed the medical records of three male adolescents of 15 years (range 13–16 years) with acute multifocal haematogenous osteomyelitis. All patients were athletes (soccer player, water polo player, practicing rowing). The mean duration of painful symptoms before seeking medical attention was 3 days. Osteomyelitis was confirmed by magnetic resonance imaging (MRI) and bone three phase scintigraphy. The lesions were at level of spine plus left femur in the first case, bilateral tibia and lumbosacral column in the second one, right foot plus left femur were interested in the third case. Two of the patients exhibited a spinal osteomyelitis, which is described as a common spinal affection in athletes. Blood cultures (in all patients) and culture of abscess drainage (in one case) were positive for Staphylococcus aureus (MSSA). Inflammatory indices were increased in all patients (mean values: WBC 15.130/mmc, CRP 19 mg/dl, and ESR 63,6 mm/h). Intravenous antibiotic therapy was prescribed for 19 days (range 13–33 days), followed by oral antibiotic therapy for a median of 18 days. After a median of 11 days, all patients clinically improved with resolution of fever and reduction of pain. Patients were discharged with oral antibiotic therapy after a median of 22 days hospitalization, and underwent a 16 months follow up. No patient reported sequelae. Differential diagnosis among multifocal acute osteomyelitis, septic arthritis, CRMO, juvenile idiopathic arthritis and/or reactive arthritis may be difficult. Previous studies reported that athletes are more at risk for osteomyelitis, but, to our knowledge, no case series of acute haematogenous multifocal infectious have been reported in competitive athletes. Staphylococcal outbreaks have been reported in sport players, as position, artificial grass abrasion, and body shaving are the main portal of bacterial entry. In conclusion, a diagnosis of acute multifocal osteomyelitis must be considered in a patient with fever and pain of several bones. A prompt hospitalization and an appropriate therapy reduce the morbidities and can help to avoid surgery

Introduction:. One of the complications occurring after total knee arthroplasty (TKA) is venous thromboembolism (VTE). The current screening techniques for VTE are venography, lower extremity vascular ultrasound, pulmonary scintigraphy, and contrast-enhanced computed tomography (CT). Although venography and lower extremity vascular ultrasound can detect deep venous thrombosis (DVT) in the lower extremities, pulmonary thrombosis poses a diagnostic problem. We performed contrast-enhanced CT screening for DVT and pulmonary embolism (PE) after TKA, and assessed the efficacy of the following prophylactics for VTE: fondaparinux, enoxaparin, and edoxaban. Materials and Methods:. Subjects included 219 patients (260 knees) undergoing TKA at our hospital between April 2007 and November 2012. The 260 subject knees were divided as follows: group C, 31 cases in which DVT prophylactics were not used (April 2007 to October 2008); group F, 107 cases receiving fondaparinux 2.5 mg/day (July 2007 to October 2009); group ENO, 87 cases receiving enoxaparin 2000–4000 IU/day (November 2009 to October 2011); and group EDO, 35 cases receiving edoxaban 15–30 mg/day (November 2011 to November 2012). Contrast-enhanced CT images were obtained from the pulmonary apex to the foot for diagnosis of VTE. Groups were compared for incidence of symptomatic PE, asymptomatic PE, DVT-negative asymptomatic PE, DVT-positive asymptomatic PE, and DVT. Results:. Incidence of symptomatic PE tended to be lower in group ENO than in group C (p = 0.067), but no statistically significant differences in asymptomatic PE were observed between any groups (Figure 1). DVT-negative asymptomatic PE (Figure 2) was present in 2 cases in group C (6.5%), 14 cases in group F (13.1%), 3 cases in group ENO (3.4%), and 2 cases in group EDO (5.7%) (Figure 1). Patients diagnosed with symptomatic PE presented only with mild clinical symptoms and physical findings. As a result, PE was not suspected from clinical findings alone. The diagnosis of symptomatic PE was confirmed by the presence of thrombosis in the pulmonary artery on contrast-enhanced CT (Figure 3). Conclusion:. Asymptomatic PE is not prevented by prophylaxis after TKA. Contrast-enhanced CT screening is effective for identifying asymptomatic VTE, especially asymptomatic PE

Introduction. Core decompression is used in precollapse lesions to forestall disease progression in avascular necrosis (AVN) of femoral head (FH). The author reports a new technique using reverse bone graft technique to effectuate core decompression. Aim. To prevent precollapse in Ficat Type 1&2 and revascularization using synthetic bone graft material. Methods. A 18 year female police trainee with Magnetic Resonance Imaging (MRI) confirming AVN Stage 2 Ficat, clinically painful hip not evident in x-rays consented to undergo this new technique. Reverse bone graft technique with a Coring reamer – Patent 5423823. A minimally invasive technique with lateral 2 cm incision introducing 8.5 mm core reamer to remove a core of bone up to the subchondral bone. The subchondral cyst decompressed and curetted under video recorded Image Intensifier (II). Demarcated avascular bone segment excised and bone graft reversed and inserted with cortical bone acting as a support to prevent collapse and the distal segment augmented using 5 grams of osteoconductive granular synthetic bone graft material based on calcium phosphate hydroxyapatite (HA 2500–5000 μm). Avascular segment histopathologically confirmed AVN. The metaphyseal entry was extrapoliated at the lateral cortex using the combined necrotic angle described by Kerboul in the anteroposterior and lateral views under II. Protected weight bearing for 2 months to prevent stress riser. Biomaterials. HA granules named as GranuMas™ developed under Intensified Research in Priority Areas (IRPA) Research Project (No. 03-01-03-0000-PR0026/05) and invented by the Advance Materials Research Centre (AMREC) and manufactured by GranuLab –Patent P1 20040748 fulfilling the criteria for American Society for Testing and Materials (ASTM) F1185-88(1993) Standards which is ‘Standard Specification for Composition of Ceramic Hydroxyapatite for Surgical Implants’. Derived from Malaysian limestone, ranging from 200–5000 μm gamma sterilized. Results. After 6 months, there was no collapse of subchondral bone and the FH showed revascularization along bone grafted site with viable graft and increased radiotracer activity using 99-Tc MDP Bone Planar Scintigraphy. Clinical analysis follow up at 2 years was descriptive rather than statistical with a x-ray evident incorporated graft and with pain free full range of movement. Discussion. Reduction in intraosseous pressure is achieved by using large bore 8.5 mm coupled with HA granules promoting revascularization. The core tract entering through the metaphyseal region reduces risk of subtrochanteric fracture a potential complication of vascularized fibular grafts and with less morbidity with other treatment methods for osteonecrosis of the femoral head. The concept can be extended in introducing stem cell and biologic material to treat AVN. Conclusion. This technique is minimally invasive and effective in young patients with early stage of FH AVN and has shown revascularization along the bone grafted site

We performed a systematic review and meta-analysis to compare the efficacy of intermittent mechanical compression combined with pharmacological thromboprophylaxis, against either mechanical compression or pharmacological prophylaxis in preventing deep-vein thrombosis (DVT) and pulmonary embolism in patients undergoing hip or knee replacement. A total of six randomised controlled trials, evaluating a total of 1399 patients, were identified. In knee arthroplasty, the rate of DVT was reduced from 18.7% with anticoagulation alone to 3.7% with combined modalities (risk ratio (RR) 0.27, p = 0.03; number needed to treat: seven). There was moderate, albeit non-significant, heterogeneity (I² = 42%). In hip replacement, there was a non-significant reduction in DVT from 8.7% with mechanical compression alone to 7.2% with additional pharmacological prophylaxis (RR 0.84) and a significant reduction in DVT from 9.7% with anticoagulation alone to 0.9% with additional mechanical compression (RR 0.17, p < 0.001; number needed to treat: 12), with no heterogeneity (I² = 0%). The included studies had insufficient power to demonstrate an effect on pulmonary embolism.

We conclude that the addition of intermittent mechanical leg compression augments the efficacy of anticoagulation in preventing DVT in patients undergoing both knee and hip replacement. Further research on the role of combined modalities in thromboprophylaxis in joint replacement and in other high-risk situations, such as fracture of the hip, is warranted.

Over a 13-year period we studied all patients who underwent major hip and knee surgery and were diagnosed with objectively confirmed symptomatic venous thromboembolism, either deep venous thrombosis or non-fatal pulmonary embolism, within six months after surgery. Low-molecular-weight heparin had been given while the patients were in hospital.

There were 5607 patients. The cumulative incidence of symptomatic venous thromboembolism was 2.7% (150 of 5607), of which 1.1% had developed pulmonary embolism, 1.5% had deep venous thrombosis and 0.6% had both. Patients presented with deep venous thrombosis at a median of 24 days and pulmonary embolism at 17 days after surgery for hip fracture. After total hip replacement, deep venous thrombosis and pulmonary embolism occurred at a median of 21 and 34 days respectively. After total knee replacement, the median time to the presentation of deep venous thrombosis and pulmonary embolism was 20 and 12 days respectively. The cumulative risk of venous thromboembolism lasted for up to three months after hip surgery and for one month after total knee replacement. Venous thromboembolism was diagnosed after discharge from hospital in 70% of patients who developed this complication.

Despite hospital-based thromboprophylaxis, most cases of clinical venous thromboembolism occur after discharge and at different times according to the operation performed.