ENGLISH ABSTRACT: Background: The detection of bone infection can be very difficult especially in bone with altered
structure due to prior trauma or surgical procedures. Complicated osteomyelitis (COM) is becoming a
public health problem especially with the difficult choice between, high cost surgery and prolonged
courses of intravenous or oral antibiotic therapy, as well as the social and psychological effect of longterm
disease and disability of the patient. The correct localisation of especially bone infection is still a
challenge for the clinician. The single photon emission computed tomography/low dose computed
tomography (SPECT/CT), by fusing the functional information with the anatomical parts, is a wellestablished
tool used in many nuclear medicine studies. This improves the overall quality of the study
with more clear answers. The aim of the study was to determine the added value of SPECT/CT in the
management of complicated osteomyelitis (COM) in patients with endo-prosthesis, post traumatic
osteomyelitis with and without metal implants and diabetic foot.
Methods: This was a prospective study, between February 2010 and February 2012. Patients with
suspected COM who fulfilled the selection and inclusion criteria were included. All had abnormal three
phase bone scan followed by infection imaging with 99mTc labelled white blood cells and 99mTc -colloid if
the99mTc labelled white blood cell study was abnormal. 67Ga citrate was used in vertebral involvement.
Planar and SPECT/CT images were reviewed for presence of abnormal uptake and for its localization in
bone and soft tissue. Scan results were defined as positive or negative. Both planar and SPECT/CT
images were compared regarding diagnosis and precise localization of infection. The final diagnosis was
obtained from surgical specimen or microbiological culture as well as clinical follow-up of all patients.
Results: There were 72 patients, 29 male and 43 female with mean age of 57 yrs [range 27-88].There
were 24 patients with prosthesis, 16 with hip prosthesis (PH=16), and 8 with knee prosthesis (PK=8).
There were 44 patients with post traumatic osteomyelitis, 26 with metal implants (TOM=26) and 18
without metal implants (TOWM= 18). Four patients had diabetic foot (DF= 4). Infection was diagnosed
in 19/72 patients on planar images and in 21/72 on SPECT/CT. Infection was diagnosed in 4 patients
with prosthesis, 16 patients with post traumatic injury and one diabetic foot patient. The four patients
with prosthesis, SPECT /CT added diagnostic value by excluding osteomyelitis in 3 patients and by
defining the exact extent and localizing soft tissue and bone infection (STI/OM) in one patient. In 16
patients with post traumatic OM on planar images, SPECT /CT added diagnostic value, by excluding OM in 4 patients and confirming only STI, better localisation of the uptake in bone
and soft tissue in 5 patients, of them 2 patient was negative on planar, and in 7 patients, confirmed and
defined the exact extent of
both OM and STI. One diabetic foot was positive for STI on the planar, the SPECT/CT added diagnostic
value by defining the extent of the infection.
In summary the added value of SPECT/CT was:
a. Overall infection:
1. Exclusion of osteomyelitis by confirming only soft tissue involvement: 7 patients (10%)
2. Better localization in bone and soft tissue: 6 patients (8%)
3. Better delineation of extent of infection: 9 patients (12%)
4. None: 50 patients (70%)
b. In positive cases only:
1. Exclusion of osteomyelitis by confirming only soft tissue involvement: 7 patients (33%)
2. Better localization in bone and soft tissue: 5 patients (24%)
3. Better delineation of extent of infection: 9 patients (43%)
4. None: 0 patients
The overall sensitivity, specificity, positive predictive value, negative predictive value and accuracy for
infection, on planar was 90%, 100%, 100%, 97%, 97%, respectively and for SPECT/CT 100%, 100%,
100%, 100%, 100%. For OM on planar, the sensitivity, specificity , positive predictive value, negative
predictive value and accuracy was 100%, 89%, 53%, 100%, 90%, respectively and for SPECT/CT 100%,
100%, 100%, 100%, 100%.
Conclusion:
In complicated osteomyelitis, SPECT/CT is useful in localizing, defining the exact extent of infection
where the planar images are abnormal, with no added value if the planar images are negative. We
recommend in clinical practice the routine use of hybrid SPECT/CT imaging in complicated osteomyelitis
when planar images are abnormal. / AFRIKAANSE OPSOMMING: Agtergrond: Die opspoor van beeninfeksie is veral moeilik in been wat as gevolg van vorige trauma of
chirurgiese prosedures misvorm is. Gekompliseerde osteomiëlitis word ‘n gesondheidsprobleem veral
as gevolg van die moeilike keuse tussen hoë koste chirurgie en langdurige kursusse binneaarse of orale
antibiotika, asook die sosiale en sielkundige gevolge van langstaande siekte en die gestremdheid van die
pasiënt.
Die korrekte lokalisering van veral beeninfeksie is steeds ‘n uitdaging vir die geneesheer. Enkel foton
emissie rekenaartomografie / lae dosis rekenaartomografie (SPECT/CT), die kombinasie van funksionele
en anatomiese inligting, is ‘n goed gevestigde metode in baie kerngeneeskunde ondersoeke. Dit
verbeter die algemene kwaliteit van die studie met ‘n meer spesifieke antwoord. Die doel van hierdie
studie was om die bykomende waarde van SPECT/CT in die hantering van gekompliseerde osteomiëlitis
in pasiënte met endo-protese, post traumatise osteomiëlitis met en sonder metaal prosteses asook
diabetiese voet te bepaal.
Metode: ‘n Prospektiewe studie is tussen Februarie 2010 en Februarie 2012 gedoen. Pasiënte met
vermoedelik gekompliseerde osteomiëlitis wat aan die keuse en insluitingskriteria voldoen het, is
ingesluit. Almal het abnormale drie-fase beenflikkergramme gehad, gevolg deur infeksiebeelding met
99mTc gemerkte witselle en 99mTc kolloïed indien die 99mTc gemerkte witselstudie abnormaal was.
67Ga sitraat is gebruik wanneer daar werwelaantasting teenwoordig was. Die planare en SPECT/CT
beelde is vergelyk ten opsigte van diagnose en presiese lokalisering van die infeksie. Die finale diagnose
is met behulp van chirurgiese monsters en mikrobiologiese kweking asook die kliniese opvolg van alle
pasiënte bepaal.
Resultate: Die studie het 72 pasiënte, 29 mans en 43 vroue, met gemiddelde ouderdom van 57 jaar [27
– 88 ingesluit]. Daar was 24 pasiënte met prosteses, waarvan 16 met heupprosteses (PH= 16) en 8 met
knieprosteses (PK= 8). Van die 44 pasiënte met post traumatiese osteomiëlitis, het 26 metaal prosteses
(TOM= 26) en 18 geen metaalprosteses gehad nie (TOWM= 18). Vier pasiënte het diabetiese voet gehad
(DF= 4). By 19/72 van die pasiënte is infeksie op die planare beelde gediagnoseer en in 21/72 op die
SPECT/CT beelde. Die bykomende twee gevalle was 1 met TOM en 1 met TOWM.
Infeksie is by 4 pasiënte met prosteses, 16 pasiënte met post traumatiese besering en 1 met diabetiese
voet gediagnoseer. In die vier pasiënte met prosteses, het SPECT/CT ‘n diagnostiese bydrae gelewer om
osteomiëlitis by 3 van die pasiënte uit te skakel en die presiese omvang en lokalisering van sagte weefsel en beeninfeksie (STI/OM) in een pasiënt te bepaal. In 16 pasiënte met
post traumatise osteomiëlitis op die planare beelde, was SPECT/CT van diagnostiese waarde, waar
osteomiëlitis in 4 pasiënte uitgesluit is, en slegs STI bevestig is. Beter lokalisering van die opname in
been en sagte weefsel was in 5 pasiënte moontlik, van wie 2 op die planare beelde negatief was, en in 7
pasiënte bevestig en die presiese omvang met beide OM en STI gedefinieer is. Een diabetiese voet was
positief vir STI op die planare beelde, maar die SPECT/CT het diagnostiese waarde verbeter deur die
omvang van die infeksie beter te toon.
Ter opsomming, was die waarde van die SPECT/CT:
1. Uitsluiting van osteomiëlitis deur slegs van sagte weefsel aantasting te bevestig:
7 pasiënte 10%
2. Beter lokalisering in been en sagte weefsel: 5 pasiënte 7%
3. Beter definisie van omvang van infeksie: 9 pasiënte 12%
4. Geen bykomende waarde: 51 pasiënte 71%
Die algehele sensitiwiteit, spesifisiteit, positiewe voorspellingswaarde, negatiewe voorspellingswaarde
en akkuraatheid vir die opspoor van infeksie vir die planare beelde was 90%, 100%, 100%, 97%, 97%,
onderskeidelik en vir die SPECT/CT 100%, 100%, 100%, 100% en 100%. Vir osteomiëlitis was
sensitiwiteit, spesifisiteit, positiewe voorspellingswaarde, negatiewe voorspellingswaarde en
akkuraatheid van planare beelde 100%, 89%, 53%, 100%, 90%, onderskeidelik en die van SPECT/CT
100%, 100%, 100%, 100% , 100%.
Gevolgtrekking: SPECT/CT is nuttig in die lokalisering en definiëring van die presiese omvang van die
infeksie in gekompliseerde osteomiëlitis in gevalle waar die planare beelde abnormaal is, met geen
bykomende waarde wanneer planare beelde negatief is nie. Ons beveel SPECT/CT beelding as roetine in
kliniese praktyk aan wanneer planare beelde in gekompliseerde osteomiëlitis abnormaal is.
| Identifer | oai:union.ndltd.org:netd.ac.za/oai:union.ndltd.org:sun/oai:scholar.sun.ac.za:10019.1/85553 |
| Date | 12 1900 |
| Creators | Tag, Naima |
| Contributors | Korowlay, Nisaar A. |
| Publisher | Stellenbosch : Stellenbosch University |
| Source Sets | South African National ETD Portal |
| Language | en_ZA |
| Detected Language | Unknown |
| Type | Thesis |
| Format | 27 p. : ill. |
| Rights | Stellenbosch University |
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