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Prosthesis infection: diagnosis after total joint arthroplasty with three-phase bone scintigraphy

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Abstract

Objective

This study investigated the diagnostic validity of Three-phase bone scintigraphy (TPBS) for diagnosing prosthetic joint infection (PJI) in cases of suspected infected total joint arthroplasty.

Methods

We performed a systematic search using MEDLINE, EMBASE, and OVID databases to conduct pertinent data published between January 1990 and December 2013. Meta-analysis was used to pool sensitivity, specificity, diagnostic odds ratios (DORs), positive likelihood ratios (PLR), negative likelihood ratios (NLR), the area under the receiver-operating characteristic curve (AUC), and post-test probability. Heterogeneity and publication bias were assessed, and subgroup and meta-regression analyses were conducted.

Results

Twenty articles including a total of 704 patients were considered for analysis. The pooled sensitivity and specificity for using TPBS to detect PJI was 0.83 [95 % confidence interval (CI) 0.72–0.90] and 0.73 (95 % CI 0.65–0.80), respectively. The AUC, PLR, NLR, and DOR were 0.85 (95 % CI 0.81–0.87), 3.1 (95 % CI 2.4–4.1), 0.23 (95 % CI 0.14–0.38), and 14 (95 % CI 7–26), respectively. Low clinical scenario-negative post-test probabilities were 7 %, and high clinical scenario-positive post-test probabilities were 90 %. Subgroup analyses indicated that the sensitivity and specificity of TPBS for detecting infected arthroplasty of the hip (0.81 and 0.78, respectively) were significantly higher than those of the knee (0.75 and 0.55, respectively; p < 0.05). There was no significant evidence of publication bias (p = 0.34).

Conclusions

TPBS has reasonable diagnostic value for detecting PJI and could be performed as a screening test or part of preoperative tests and analysed in conjunction with other findings at the time of suspected PJI, especially in those infections affecting the hip.

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References

  1. Mont MA, Waldman BJ, Hungerford DS. Evaluation of preoperative cultures before second-stage reimplantation of a total knee prosthesis complicated by infection. A comparison-group study. J Bone Joint Surg Am. 2000;82-A:1552–7.

    CAS  PubMed  Google Scholar 

  2. Clohisy JC, Calvert G, Tull F, McDonald D, Maloney WJ. Reasons for revision hip surgery: a retrospective review. Clin Orthop Relat Res. 2004;429:188–92.

    Article  PubMed  Google Scholar 

  3. Del Pozo JL, Patel R. Clinical practice. Infection associated with prosthetic joints. N Engl J Med. 2009;361:787–94.

    Article  PubMed Central  PubMed  Google Scholar 

  4. Gratz S, Hoffken H, Kaiser JW, Behr TM, Strosche H, Reize P. Nuclear medical imaging in case of painful knee arthroplasty. Radiologe. 2009;49:59–67.

    Article  CAS  PubMed  Google Scholar 

  5. Gratz S, Schipper ML, Dorner J, Hoffken H, Becker W, Kaiser JW, Behe M, Behr TM. LeukoScan for imaging infection in different clinical settings: a retrospective evaluation and extended review of the literature. Clin Nucl Med. 2003;28:267–76.

    CAS  PubMed  Google Scholar 

  6. Roder C, Eggli S, Aebi M, Busato A. The validity of clinical examination in the diagnosis of loosening of components in total hip arthroplasty. J Bone Joint Surg Br. 2003;85:37–44.

    Article  CAS  PubMed  Google Scholar 

  7. Love C, Marwin SE, Tomas MB, Krauss ES, Tronco GG, Bhargava KK, Nichols KJ, Palestro CJ. Diagnosing infection in the failed joint replacement: a comparison of coincidence detection 18F-FDG and 111In-labeled leukocyte/99mTc-sulfur colloid marrow imaging. J Nucl Med. 2004;45:1864–71.

    PubMed  Google Scholar 

  8. Love C, Tomas MB, Marwin SE, Pugliese PV, Palestro CJ. Role of nuclear medicine in diagnosis of the infected joint replacement. Radiographics. 2001;21:1229–38.

    Article  CAS  PubMed  Google Scholar 

  9. Patel R, Osmon DR, Hanssen AD. The diagnosis of prosthetic joint infection: current techniques and emerging technologies. Clin Orthop Relat Res. 2005;437:55–8.

    Article  PubMed  Google Scholar 

  10. Mariani BD, Martin DS, Levine MJ, Booth RE Jr, Tuan RS. The Coventry Award. Polymerase chain reaction detection of bacterial infection in total knee arthroplasty. Clin Orthop Relat Res. 1996;331:11–22.

    Article  PubMed  Google Scholar 

  11. Schauwecker DS. The scintigraphic diagnosis of osteomyelitis. AJR Am J Roentgenol. 1992;158:9–18.

    Article  CAS  PubMed  Google Scholar 

  12. Rubello D, Rampin L, Banti E, Grassetto G, Massaro A, Cittadin S, Pavan L, Cattelan AM, Fanti S, Al-Nahhas A, Gross MD, Alavi A. Antigranulocyte scintigraphy in infected hip prosthesis: the diagnostic importance of delayed 20–24-h imaging and semiquantitative analysis. Nucl Med Commun. 2008;29:994–8.

    Article  PubMed  Google Scholar 

  13. Nagoya S, Kaya M, Sasaki M, Tateda K, Yamashita T. Diagnosis of peri-prosthetic infection at the hip using triple-phase bone scintigraphy. J Bone Joint Surg Br. 2008;90:140–4.

    Article  CAS  PubMed  Google Scholar 

  14. Reinartz P, Mumme T, Hermanns B, Cremerius U, Wirtz DC, Schaefer WM, Niethard F, Buell U. Radionuclide imaging of the painful hip arthroplasty: positron-emission tomography versus triple-phase bone scanning. J Bone Joint Surg Br. 2005;87:465–70.

    Article  CAS  PubMed  Google Scholar 

  15. Mumme T, Reinartz P, Alfer J, Muller-Rath R, Buell U, Wirtz DC. Diagnostic values of positron emission tomography versus triple-phase bone scan in hip arthroplasty loosening. Arch Orthop Trauma Surg. 2005;125:322–9.

    Article  CAS  PubMed  Google Scholar 

  16. Stumpe KD, Notzli HP, Zanetti M, Kamel EM, Hany TF, Gorres GW, von Schulthess GK, Hodler J. FDG PET for differentiation of infection and aseptic loosening in total hip replacements: comparison with conventional radiography and three-phase bone scintigraphy. Radiology. 2004;231:333–41.

    Article  PubMed  Google Scholar 

  17. Larikka MJ, Ahonen AK, Niemela O, Junila JA, Hamalainen MM, Britton K, Syrjala HP. Comparison of 99mTc ciprofloxacin, 99mTc white blood cell and three-phase bone imaging in the diagnosis of hip prosthesis infections: improved diagnostic accuracy with extended imaging time. Nucl Med Commun. 2002;23:655–61.

    Article  CAS  PubMed  Google Scholar 

  18. Larikka MJ, Ahonen AK, Junila JA, Niemela O, Hamalainen MM, Syrjala HP. Extended combined 99mTc-white blood cell and bone imaging improves the diagnostic accuracy in the detection of hip replacement infections. Eur J Nucl Med. 2001;28:288–93.

    Article  CAS  PubMed  Google Scholar 

  19. Itasaka T, Kawai A, Sato T, Mitani S, Inoue H. Diagnosis of infection after total hip arthroplasty. J Orthop Sci. 2001;6:320–6.

    Article  CAS  PubMed  Google Scholar 

  20. Lieberman JR, Huo MH, Schneider R, Salvati EA, Rodi S. Evaluation of painful hip arthroplasties. Are technetium bone scans necessary? J Bone Joint Surg Br. 1993;75:475–8.

    CAS  PubMed  Google Scholar 

  21. Bernay I, Akinci M, Kitapci M, Tokgozoglu N, Erbengi G. The value of Tc-99m Nanocolloid scintigraphy in the evaluation of infected total hip arthroplasties. Ann Nucl Med. 1993;7:215–22.

    Article  CAS  PubMed  Google Scholar 

  22. Gratz S, Reize P, Pfestroff A, Hoffken H. Intact versus fragmented 99mTc-monoclonal antibody imaging of infection in patients with septically loosened total knee arthroplasty. J Int Med Res. 2012;40:1335–42.

    Article  CAS  PubMed  Google Scholar 

  23. Larikka MJ, Ahonen AK, Junila JA, Niemela O, Hamalainen MM, Syrjala HP. Improved method for detecting knee replacement infections based on extended combined 99mTc-white blood cell/bone imaging. Nucl Med Commun. 2001;22:1145–50.

    Article  CAS  PubMed  Google Scholar 

  24. Sacchetti GM, Ghisellini F, Brambilla M, De Consoli A, Fornara P, Rizzo E, Rudoni M, Inglese E, Cannas M. Quantitative scintigraphic evaluation of total knee arthroplasties: a feasibility study. Clin Orthop Relat Res. 1996;325:181–9.

    Article  PubMed  Google Scholar 

  25. Owen RJ, Harper WM, Finlay DB, Belton IP. Isotope bone scans in patients with painful knee replacements: do they alter management? Br J Radiol. 1995;68:1204–7.

    Article  CAS  PubMed  Google Scholar 

  26. Palestro CJ, Swyer AJ, Kim CK, Goldsmith SJ. Infected knee prosthesis: diagnosis with In-111 leukocyte, Tc-99m sulfur colloid, and Tc-99m MDP imaging. Radiology. 1991;179:645–8.

    Article  CAS  PubMed  Google Scholar 

  27. Deville WL, Buntinx F, Bouter LM, Montori VM, de Vet HC, van der Windt DA, Bezemer PD. Conducting systematic reviews of diagnostic studies: didactic guidelines. BMC Med Res Methodol. 2002;2:9.

    Article  PubMed Central  PubMed  Google Scholar 

  28. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Ann Intern Med. 2009;151:W65–94.

    Article  PubMed  Google Scholar 

  29. Berlin JA. Does blinding of readers affect the results of meta-analyses? University of Pennsylvania Meta-analysis Blinding Study Group. Lancet. 1997;350:185–6.

    Article  CAS  PubMed  Google Scholar 

  30. Whiting P, Rutjes AW, Reitsma JB, Bossuyt PM, Kleijnen J. The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol. 2003;3:25.

    Article  PubMed Central  PubMed  Google Scholar 

  31. Moses LE, Shapiro D, Littenberg B. Combining independent studies of a diagnostic test into a summary ROC curve: data-analytic approaches and some additional considerations. Stat Med. 1993;12:1293–316.

    Article  CAS  PubMed  Google Scholar 

  32. Huedo-Medina TB, Sanchez-Meca J, Marin-Martinez F, Botella J. Assessing heterogeneity in meta-analysis: Q statistic or I2 index? Psychol Methods. 2006;11:193–206.

    Article  PubMed  Google Scholar 

  33. Deeks JJ, Macaskill P, Irwig L. The performance of tests of publication bias and other sample size effects in systematic reviews of diagnostic test accuracy was assessed. J Clin Epidemiol. 2005;58:882–93.

    Article  PubMed  Google Scholar 

  34. Sharkey PF, Hozack WJ, Rothman RH, Shastri S, Jacoby SM. Install Award paper. Why are total knee arthroplasties failing today? Clin Orthop Relat Res. 2002;404:7–13.

    Article  PubMed  Google Scholar 

  35. Trampuz A, Piper KE, Jacobson MJ, Hanssen AD, Unni KK, Osmon DR, Mandrekar JN, Cockerill FR, Steckelberg JM, Greenleaf JF, Patel R. Sonication of removed hip and knee prostheses for diagnosis of infection. N Engl J Med. 2007;357:654–63.

    Article  CAS  PubMed  Google Scholar 

  36. Parvizi J, Adeli B, Zmistowski B, Restrepo C, Greenwald AS. Management of periprosthetic joint infection: the current knowledge: AAOS exhibit selection. J Bone Joint Surg Am. 2012;94:e104.

    Article  PubMed  Google Scholar 

  37. Berbari E, Mabry T, Tsaras G, Spangehl M, Erwin PJ, Murad MH, Steckelberg J, Osmon D. Inflammatory blood laboratory levels as markers of prosthetic joint infection: a systematic review and meta-analysis. J Bone Joint Surg Am. 2010;92:2102–9.

    Article  PubMed  Google Scholar 

  38. Pakos EE, Trikalinos TA, Fotopoulos AD, Ioannidis JP. Prosthesis infection: diagnosis after total joint arthroplasty with antigranulocyte scintigraphy with 99mTc-labeled monoclonal antibodies–a meta-analysis. Radiology. 2007;242:101–8.

    Article  PubMed  Google Scholar 

  39. Kwee TC, Kwee RM, Alavi A. FDG-PET for diagnosing prosthetic joint infection: systematic review and metaanalysis. Eur J Nucl Med Mol Imaging. 2008;35:2122–32.

    Article  PubMed  Google Scholar 

  40. Chacko TK, Zhuang H, Stevenson K, Moussavian B, Alavi A. The importance of the location of fluorodeoxyglucose uptake in periprosthetic infection in painful hip prostheses. Nucl Med Commun. 2002;23:851–5.

    Article  CAS  PubMed  Google Scholar 

  41. Zhuang H, Duarte PS, Pourdehnad M, Maes A, Van Acker F, Shnier D, Garino JP, Fitzgerald RH, Alavi A. The promising role of 18F-FDG PET in detecting infected lower limb prosthesis implants. J Nucl Med. 2001;42:44–8.

    CAS  PubMed  Google Scholar 

  42. Van Acker F, Nuyts J, Maes A, Vanquickenborne B, Stuyck J, Bellemans J, Vleugels S, Bormans G, Mortelmans L. FDG-PET, 99mTc-HMPAO white blood cell SPET and bone scintigraphy in the evaluation of painful total knee arthroplasties. Eur J Nucl Med. 2001;28:1496–504.

    Article  PubMed  Google Scholar 

  43. Keogh CF, Munk PL, Gee R, Chan LP, Marchinkow LO. Imaging of the painful hip arthroplasty. AJR Am J Roentgenol. 2003;180:115–20.

    Article  PubMed  Google Scholar 

  44. Reinartz P. FDG-PET in patients with painful hip and knee arthroplasty: technical breakthrough or just more of the same. Q J Nucl Med Mol Imaging. 2009;53:41–50.

    CAS  PubMed  Google Scholar 

  45. Palermo F, Boccaletto F, Paolin A, Carniato A, Zoli P, Giusto F, Turra S. Comparison of technetium-99m-MDP, technetium-99m-WBC and technetium-99m-HIG in musculoskeletal inflammation. J Nucl Med. 1998;39:516–21.

    CAS  PubMed  Google Scholar 

  46. Delank KS, Schmidt M, Michael JW, Dietlein M, Schicha H, Eysel P. The implications of 18F-FDG PET for the diagnosis of endoprosthetic loosening and infection in hip and knee arthroplasty: results from a prospective, blinded study. BMC Musculoskelet Disord. 2006;7:20.

    Article  PubMed Central  PubMed  Google Scholar 

  47. Palestro CJ, Kipper SL, Weiland FL, Love C, Tomas MB. Osteomyelitis: diagnosis with (99m)Tc-labeled antigranulocyte antibodies compared with diagnosis with (111)In-labeled leukocytes–initial experience. Radiology. 2002;223:758–64.

    Article  PubMed  Google Scholar 

  48. Chik KK, Magee MA, Bruce WJ, Higgs RJ, Thomas MG, Allman KC, Van der Wall H. Tc-99m stannous colloid-labeled leukocyte scintigraphy in the evaluation of the painful arthroplasty. Clin Nucl Med. 1996;21:838–43.

    Article  CAS  PubMed  Google Scholar 

  49. Scheidler J, Leinsinger G, Pfahler M, Kirsch CM. Diagnosis of osteomyelitis. Accuracy and limitations of antigranulocyte antibody imaging compared to three-phase bone scan. Clin Nucl Med. 1994;19:731–7.

    Article  CAS  PubMed  Google Scholar 

  50. Sciuk J, Puskas C, Greitemann B, Schober O. White blood cell scintigraphy with monoclonal antibodies in the study of the infected endoprosthesis. Eur J Nucl Med. 1992;19:497–502.

    Article  CAS  PubMed  Google Scholar 

  51. Della Valle CJ, Sporer SM, Jacobs JJ, Berger RA, Rosenberg AG, Paprosky WG. Preoperative testing for sepsis before revision total knee arthroplasty. J Arthroplasty. 2007;22:90–3.

    Article  PubMed  Google Scholar 

  52. Palestro CJ. Nuclear medicine, the painful prosthetic joint, and orthopedic infection. J Nucl Med. 2003;44:927–9.

    PubMed  Google Scholar 

  53. Osmon DR, Berbari EF, Berendt AR, Lew D, Zimmerli W, Steckelberg JM, Rao N, Hanssen A, Wilson WR. Infectious diseases society of A. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the infectious diseases society of America. Clin Infect Dis. 2013;56:e1–25.

    Article  PubMed  Google Scholar 

  54. Johnson JA, Christie MJ, Sandler MP, Parks PF Jr, Homra L, Kaye JJ. Detection of occult infection following total joint arthroplasty using sequential technetium-99m HDP bone scintigraphy and indium-111 WBC imaging. J Nucl Med. 1988;29:1347–53.

    CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Orthopaedics, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410011, Hunan, China

    Zhengxiao Ouyang, Haowei Li, Xuqiang Liu, Zanjing Zhai & Xianan Li

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  1. Zhengxiao Ouyang
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  2. Haowei Li
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Correspondence to Zanjing Zhai or Xianan Li.

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Z. Ouyang and H. Li contributed equally to this work.

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Ouyang, Z., Li, H., Liu, X. et al. Prosthesis infection: diagnosis after total joint arthroplasty with three-phase bone scintigraphy. Ann Nucl Med 28, 994–1003 (2014). https://doi.org/10.1007/s12149-014-0899-5

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