Advertisement

Three-phase Technetium-99m bone scanning in patients with pain in the knee region after cemented total knee arthroplasty

  • Daniel S. HillEmail author
  • Denis Kinsella
  • Andrew D. Toms
Original Article • KNEE - ARTHROPLASTY
  • 50 Downloads

Abstract

Introduction

Our aim was to question the usefulness of a three-phase bone scan in the evaluation of pain in the knee region after TKR. Our hypothesis was that an abnormal investigation had a poor association with the presence of infection or loosening, and did not provide any additional diagnostic information above that already available through other standard investigations.

Methods

A retrospective study over a 24-month period was performed comprising 118 patients investigated with a TPBS. Investigations were summarised and analysed, and were classified as entirely normal, possibly abnormal, and definitely abnormal.

Results

Thirty-three per cent (39/118) of TPBSs were reported as being entirely normal, 59% (69/118) as possibly abnormal, and 8% (10/118) as definitely abnormal. During the 24-month study period, 131 revision TKR procedures were performed at our institution; 9% (12/131) were investigated with TPBS and 91% (119/131) were not. No patient with an entirely normal pre-operative TPBS underwent revision TKR surgery. Eighty-five per cent (67/79) with an abnormal TPBS were managed conservatively. In our series, a TPBS had a positive predictive value of 2.53%, a negative predictive value of 100%, with an overall accuracy of 34.75% with 100% sensitivity (97.5% one-sided confidence interval 0–24.71%), and 33.62% specificity (95% confidence interval 53.29–72.37%), in the diagnosis of infection, or loosening with concurrent infection in determining the indication for revision surgery.

Conclusion

A TPBS should only be considered following clinical evaluation, serological investigation, diagnostic imaging, and microbiological analysis of fluid obtained from arthrocentesis by a specialist revision arthroplasty surgeon. A TPBS may be useful in the situation where abnormal serology is present, but where repeated joint aspirations samples are inconclusive.

Keywords

Pain in the knee region Cemented total knee replacement Three-phase Technetium-99m bone scan Revision arthroplasty 

Notes

Acknowledgements

We would like to acknowledge the support of our Statistical Advisor Dr. Roy J. Powell, B.Sc. (Hons), Ph.D., CBIOL, FSB, FHEA. Research Design Consultant, Research Design Service (RDS) South West.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

The National Research Ethics Committee reviewed the protocol for this work and stated that formal ethical approval was not required.

References

  1. 1.
    Toms AD, Mandalia V, Haigh R, Hopwood B (2009) The management of patients with painful total knee replacement. J Bone Joint Surg Br 91(2):143–150CrossRefGoogle Scholar
  2. 2.
    Math KRSF, Petchprapa C, Harwin SFZ, Math KR, Zaidi SF, Petchprapa C, Harwin SF (2006) Imaging of total knee arthroplasty. Semin Musculoskelet Radiol 10(1):47–63CrossRefGoogle Scholar
  3. 3.
    Hofmann AA, Wyatt RW, Daniels AU, Armstrong L, Alazraki N, Taylor AJ (1990) Bone scans after total knee arthroplasty in asymptomatic patients. Cemented versus cementless. Clin Orthop Relat Res 251:183–188Google Scholar
  4. 4.
    Rosenthall L, Lepanto L, Raymond F (1987) Radiophosphate uptake in asymptomatic knee arthroplasty. J Nucl Med 28(10):1546–1549Google Scholar
  5. 5.
    Henderson JJ, Bamford DJ, Noble J, Brown JD (1996) The value of skeletal scintigraphy in predicting the need for revision surgery in total knee replacement. Orthopedics 19(4):295–299Google Scholar
  6. 6.
    Love C, Tomas MB, Marwin SE, Pugliese PV, Palestro CJ (2001) Role of nuclear medicine in diagnosis of the infected joint replacement. Radiographics 21(5):1229–1238CrossRefGoogle Scholar
  7. 7.
    Wong MY, Beadsmoore C, Toms A, Smith T, Donell S (2012) Does 99mTc-MDP bone scintigraphy add to the investigation of patients with symptomatic unicompartmental knee replacement? Knee 19(5):592–596CrossRefGoogle Scholar
  8. 8.
    Levitsky KA, Hozack WJ, Balderston RA, Rothman RH, Gluckman SJ, Maslack MM et al (1991) Evaluation of the painful prosthetic joint. Relative value of bone scan, sedimentation rate, and joint aspiration. J Arthroplasty 6(3):237–244CrossRefGoogle Scholar
  9. 9.
    Smith SL, Wastie ML, Forster I (2001) Radionuclide bone scintigraphy in the detection of significant complications after total knee joint replacement. Clin Radiol 56(3):221–224CrossRefGoogle Scholar
  10. 10.
    Temmerman OPP, Raijmakers PGHM, David EFL, Pijpers R, Molenaar MA, Hoekstra OS et al (2004) A comparison of radiographic and scintigraphic techniques to assess aseptic loosening of the acetabular component in a total hip replacement. J Bone Joint Surg Am 86–A(11):2456–2463CrossRefGoogle Scholar
  11. 11.
    Lieberman JR, Huo MH, Schneider R, Salvati EA, Rodi S (1993) Evaluation of painful hip arthroplasties. Are technetium bone scans necessary? J Bone Joint Surg Br 75(3):475–478CrossRefGoogle Scholar
  12. 12.
    Greidanus NV, Masri BA, Garbuz DS, Wilson SD, McAlinden MG, Xu M et al (2007) Use of erythrocyte sedimentation rate and C-reactive protein level to diagnose infection before revision total knee arthroplasty. A prospective evaluation. J Bone Joint Surg Am 89(7):1409–1416Google Scholar
  13. 13.
    Mandalia V, Eyres K, Schranz P, Toms AD (2008) Evaluation of patient with a painful total knee replacement. J Bone Joint Surg (British) 90-B(3):265–271CrossRefGoogle Scholar
  14. 14.
    Spangehl MJ, Masri BA, O’Connell JX, Duncan CP (1999) Prospective analysis of preoperative and intraoperative investigations for the diagnosis of infection at the sites of two hundred and two revision total hip arthroplasties. J Bone Joint Surg Am 81(5):672–683CrossRefGoogle Scholar
  15. 15.
    Moreschini O, Greggi G, Giordano MC, Nocente M, Margheritini F (2001) Postoperative physiopathological analysis of inflammatory parameters in patients undergoing hip or knee arthroplasty. Int J Tissue React 23(4):151–154Google Scholar
  16. 16.
    Parvizi J, Zmistowski B, Berbari EF, Bauer TW, Springer BD, Della Valle CJ et al (2011) New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res 469(11):2992–2994CrossRefGoogle Scholar
  17. 17.
    American Academy of orthopaedic surgeons. Guideline on the diagnosis of periprosthetic joint infections of the hip and knee Google Scholar
  18. 18.
    Duus BR, Stadeager C, Boeckstyns M (1990) The natural course of radionuclide bone scanning in the evaluation of total knee replacement. A two year perspective study. Clin Radiol 41(5):341–343CrossRefGoogle Scholar
  19. 19.
    Rubello D, Caricasulo D, Borsato N, Chierichetti F, Zanco P, Ferlin G (1996) Three-phase bone scan pattern in asymptomatic uncemented total knee arthroplasty. Eur J Nucl Med 23(10):1400–1403CrossRefGoogle Scholar
  20. 20.
    Verlooy H, Victor J, Renson L, Vandecruys A, Drent P, Mortelmans L et al (1993) Limitations of quantitative radionuclide bone scanning in the evaluation of total knee replacement. Clin Nucl Med 18(8):671–674CrossRefGoogle Scholar
  21. 21.
    Reinartz P, Mumme T, Hermanns B, Cremerius U, Wirtz DC, Schaefer WM et al (2005) Radionuclide imaging of the painful hip arthroplasty: positron-emission tomography versus triple-phase bone scanning. J Bone Joint Surg Br 87(4):465–470CrossRefGoogle Scholar

Copyright information

© Springer-Verlag France SAS, part of Springer Nature 2019

Authors and Affiliations

  • Daniel S. Hill
    • 1
    Email author
  • Denis Kinsella
    • 1
  • Andrew D. Toms
    • 1
  1. 1.Princess Elizabeth Orthopaedic CentreRoyal Devon and Exeter Foundation TrustExeterUK

Personalised recommendations