title: FDG PET for diagnosing infection in hip and knee prostheses: prospective study in 221 prostheses and subgroup comparison with combined (111)In-labeled leukocyte/(99m)Tc-sulfur colloid bone marrow imaging in 88 prostheses.
abstract: OBJECTIVE
  This study aims to assess and compare the value of FDG PET with combined In-labeled leukocyte/Tc-sulfur colloid bone marrow (WBC/BM) imaging for diagnosing infection in hip and knee prostheses.
  
  
  METHODS
  In this prospective study, patients with painful hip or knee arthroplasty, who were scheduled to undergo clinical and diagnostic evaluation for prosthesis revision, were included. They have been studied by using FDG PET and WBC/BM scan. This study was institutional review board approved and Health Insurance Portability and Accountability Act compliant. All patients provided written informed consent.
  
  
  RESULTS
  A total of 134 hip and 87 knee prostheses, suspected of being either infected or noninfectious loosening, were evaluated. All 221 prostheses underwent FDG PET, whereas both WBC/BM imaging and FDG PET were performed in 88 prostheses. The initial analysis of data from the WBC/BM images demonstrated somewhat suboptimal results compared with those of FDG PET scans on 88 patients. In addition, some patients were not willing to undergo both procedures and therefore participate in this study. Therefore, a decision was made to eliminate WBC/BM imaging from the procedures for the remainder of this research study. This decision was reached partly because of the significant radiation dose delivered from labeled WBC and safety issues related to preparing these labeled cells. Final diagnosis was based on microbiological examinations of the surgical specimens in 125 prostheses and joint aspirations combined with the clinical follow-up of 6 months or more in 86 prostheses. The sensitivity, specificity, positive predictive value, and negative predictive value of FDG PET in hip prostheses were 81.8%, 93.1%, 79.4%, and 94.0%, respectively, and in knee prostheses were 94.7%, 88.2%, 69.2%, and 98.4%, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value of WBC/BM imaging in hip prostheses were 38.5%, 95.7%, 71.4%, and 84.6%, respectively, and in knee prostheses were 33.3%, 88.5%, 25.0%, and 92.0%, respectively. In those cases that underwent both FDG PET and WBC/BM imaging, there was a trend (P = 0.0625) toward a higher sensitivity for FDG PET in hip prostheses, whereas other comparisons did not show any significant differences between the 2 imaging modalities.
  
  
  CONCLUSIONS
  Based on this study, the diagnostic performance of FDG PET scan in detecting infection in painful hip and knee prostheses is optimal for routine clinical application. Considering the complexity and costs of WBC/BM imaging and related safety issues associated with this preparation, FDG PET seems to be an appropriate alternative for assessing these patients.
authors.affiliation: From the *Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA; †Radiation Medicine Centre (BARC), Tata Memorial Centre Annexe, Parel, Bombay, Maharashtra, India; ‡Department of Radiology, University Medical Center Utrecht, Utrecht, Utrecht, the Netherlands; §Department of Orthopedic Surgery, Penn Presbyterian Medical Center, Philadelphia, PA; ¶Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA; and ∥Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, Delhi, India.
authors.forename: Sandip
authors.initials: S
authors.lastname: Basu
authors.forename: Thomas C
authors.initials: TC
authors.lastname: Kwee
authors.forename: Babak
authors.initials: B
authors.lastname: Saboury
authors.forename: Jonathan P
authors.initials: JP
authors.lastname: Garino
authors.forename: Charles L
authors.initials: CL
authors.lastname: Nelson
authors.forename: Hongming
authors.initials: H
authors.lastname: Zhuang
authors.forename: Molly
authors.initials: M
authors.lastname: Parsons
authors.forename: Wengen
authors.initials: W
authors.lastname: Chen
authors.forename: Rakesh
authors.initials: R
authors.lastname: Kumar
authors.forename: Ali
authors.initials: A
authors.lastname: Salavati
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Werner
authors.forename: Abass
authors.initials: A
authors.lastname: Alavi
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001178:Arthroplasty; D001853:Bone Marrow / Q000000981:diagnostic imaging; D005260:Female; D019788:Fluorodeoxyglucose F18; D006622:Hip Prosthesis / Q000009:adverse effects*; D006801:Humans; D007205:Indium Radioisotopes; D007720:Knee Prosthesis / Q000009:adverse effects*; D007962:Leukocytes / Q000000981:diagnostic imaging*; D008297:Male; D008875:Middle Aged; D049268:Positron-Emission Tomography; D011446:Prospective Studies; D016459:Prosthesis-Related Infections / Q000000981:diagnostic imaging* / Q000209:etiology; D012015:Reference Standards; D013671:Technetium Tc 99m Sulfur Colloid; D055815:Young Adult
chemical_list: D007205:Indium Radioisotopes; D019788:Fluorodeoxyglucose F18; D013671:Technetium Tc 99m Sulfur Colloid