technetium-tc-99m-medronate and Foot-Diseases

This article provides a brief overview of the current state of hybrid single-photon emission computed tomography/computer tomography (SPECT/CT) imaging in musculoskeletal infections. SPECT/CT imaging, compared with conventional planar study and SPECT alone, provides improved anatomic localization of infection and more accurate delineation of the extent of infection. This article emphasizes three clinical aspects where SPECT/CT is found to be most useful: differentiating between soft tissue and bone infections, assessing suspected infected sites with underlying structural bone alterations, and defining infective focus when complex anatomy is involved. The accurate assessment of site of infection is vital for selecting the most appropriate therapeutic strategy. Other advantages of SPECT/CT imaging such as reducing the inconvenience of combination planar studies, providing additional CT information, and increasing interobserver agreement are also discussed.

Topics: Bone Diseases; Child; Foot Diseases; Gallium Radioisotopes; Humans; Indium Radioisotopes; Infections; Musculoskeletal Diseases; Postoperative Complications; Soft Tissue Infections; Spinal Diseases; Technetium Tc 99m Exametazime; Technetium Tc 99m Medronate; Tomography, Emission-Computed, Single-Photon; Tomography, X-Ray Computed; Wounds and Injuries

Early and accurate diagnosis of infection or neuropathy of the diabetic foot is the key to successful management. Angiopathy leads to ischemia which, in combination with peripheral neuropathy, predisposes to pedal skin ulceration, the precursor of osteomyelitis. Chronic hyperglycemia promotes production of glycosylated end products which accumulate on endothelial proteins, causing ischemia of the vasa nervorum. When combined with axonal degeneration of the sensory nerves, the result is hypertrophic neuroarthropathy. Should the sympathetic nerve fibers also be damaged, the resultant loss of vasoconstrictive impulses leads to hyperemia and atrophic neuroarthropathy. Plain radiography, although less sensitive than radionuclide, magnetic resonance (MR), and computed tomographic examinations, should be the initial procedure for imaging suspected osteomyelitis in the diabetic patient. If the radiographs are normal but the clinical suspicion of osteomyelitis is strong, a three-phase 99mTc-MDP scan or MR imaging is recommended. An equivocal 99mTc-MDP scan should be followed by MR imaging. To exclude osteomyelitis at a site of neuroarthropathy, a 111In white blood cell scan is preferable. To obtain a specimen of bone for bacteriological studies, percutaneous core biopsy is the procedure of choice, with the entrance of the needle well beyond the edge of the subjacent ulcer.

Topics: Biopsy, Needle; Diabetic Angiopathies; Diabetic Foot; Diabetic Neuropathies; Diagnostic Imaging; Female; Foot Diseases; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Osteomyelitis; Radionuclide Imaging; Technetium Tc 99m Medronate; Tomography, X-Ray Computed

The aim of the study was to optimize imaging positions of (99m)Tc-methylene diphosphonate ((99m)Tc-MDP) 3-phase bone scanning for the accurate localization of foot pathology in patients with trauma and diabetes-related complications.. (99m)Tc-MDP 3-phase bone scanning was performed for 26 controls and 27 patients with foot pathology. Flow was acquired in 1 of the following projections: anterior-posterior, medial-lateral, or plantar. Blood-pool and delayed images were acquired in a set of 5 projections (anterior, posterior, medial, lateral, and plantar). Images from the control group were checked for the views that best visualized individual bones or regions of the foot. These views were cross-correlated with images from the patient group to see whether they localized the exact site of the foot lesion.. In the controls, the plantar view was the best view for visualization of the forefoot region. The mid foot was best assessed on the anterior view. Medial-lateral views were best suited for imaging the hind foot, and the posterior view was the best for the ankle joint. In the subjects with foot pathology, lesions were accurately assigned to the affected bone using the imaging criteria derived from the controls. In a few cases, however, additional views were needed because of overlap or shine-through of activity, particularly in mid-foot lesions.. Optimal imaging positioning of the foot by bone scanning can be achieved using 5 views, which can yield accurate localization of a particular structure or bone, thereby improving the diagnostic accuracy of the procedure.

Topics: Bone and Bones; Female; Foot Diseases; Humans; Male; Middle Aged; Prospective Studies; Radionuclide Imaging; Technetium Tc 99m Medronate

The maximum standardized uptake value (SUVmax) in single-photon emission computed tomography/computed tomography (SPECT/CT) can help quantify disease activity of the accessory navicular bone (ANB). In this multicenter quantitative bone SPECT/CT study, we investigated whether SUVmax was correlated with ANB severity, thereby allowing prediction of surgical resection for ANB treatment.. Two-hundred forty-six patients (men:women = 135:111, mean age = 39.3 years), who had undergone quantitative Tc-99m diphosphonate SPECT/CT of the feet, were recruited from four hospitals. SUVmax was measured using vendor-provided quantitation software. The SUVmax values were compared in relation to ANB type (type 1 = 62, type 2 = 136 and type 3 = 14), presence of pain and surgical treatment.. SUVmax (mean ± SD) was the highest in type 2 ANB (4.41 ± 5.2; P = 0.0101). The 17 resected ANBs showed greater SUVmax (8.27 ± 5.23; P < 0.0001) than the 141 asymptomatic ANBs (2.30 ± 1.68) or the 54 symptomatic ANBs without surgery (6.15 ± 4.40). Since surgery is exclusively indicated for ANB type 2, surgical resection was investigated only in these cases. In univariate analysis, young age and SUVmax were significantly associated with surgical treatment, but only SUVmax was a significant predictor of surgery in multivariate analysis (P < 0.0001). Type 2 ANBs were treated by surgery in 32.5% (13/40) of the cases when SUVmax was ≥5, and in only 1.35% (1/74) of the cases when SUVmax was <5 (P < 0.0001).. ANB disease activity and excision were strongly associated with the SUVmax derived from quantitative bone SPECT/CT. Our study suggests an absolute SUVmax cutoff for ultimate ANB surgical treatment, but additional prospective studies are required to validate this finding.

Topics: Adult; Female; Foot Diseases; Humans; Male; Middle Aged; Retrospective Studies; Single Photon Emission Computed Tomography Computed Tomography; Tarsal Bones; Technetium Tc 99m Medronate

Quantitative bone SPECT/CT (single-photon emission computed tomography/computed tomography) using Tc-99m hydroxymethylene diphosphonate is emerging as a useful imaging modality for skeletal diseases. Accessory navicular bone (ANB) has been evaluated by bone scintigraphy only qualitatively and semiquantitatively. However, a truly objective quantitative assessment of ANB is lacking. Here, we measured the maximum standardized uptake value (SUVmax) of the ANB and investigated its usefulness as an imaging biomarker for ANB.Consecutive quantitative bone SPECT/CT studies that had been performed on the foot were retrospectively analyzed. One hundred five patients (male:female = 44:61; median age = 32.0 [range, 11-81] years old; 31 negative controls without ANB and 74 patients with ANB [7 unilateral and 67 bilateral]) and their 210 feet were investigated. The ANBs were classified into types I, II, III (Geist classification), and 0 (contralateral navicular of unilateral ANB). Type II ANBs were subclassified into II-1 (with bony abnormality) or II-0 (without bony abnormality). The treatment modality was observation, conservative treatment, or surgical removal. The associations between the SUVmax and clinical findings, including surgery, were investigated.Patients with type II-1 ANB had the highest SUVmax among all ANB types (P < .001). The SUVmax of symptomatic ANB was greater than that for asymptomatic ANB (P < .001), and the SUVmax for the surgically resected ANB group was also significantly higher than that for the observation only or conservative treatment group (P < .001). Subtype II-1 had a significantly higher SUVmax compared with subtype II-0 (P < .001). Logistic regression analyses in type II ANB showed that young age (P = .020) and SUVmax (P = .031) were significant predictors for surgery. Receiver operating characteristic curve and survival analyses revealed an optimal SUVmax cutoff of 5.27 g/mL for predicting final surgical treatment.SUVmax derived from quantitative bone SPECT/CT was strongly associated with symptom, surgical treatment, and a known high-risk type of ANB. Risk stratification for final surgical treatment of ANB can be achieved using the SUVmax from quantitative bone SPECT/CT.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Child; Female; Foot Diseases; Humans; Male; Middle Aged; Prognosis; Radiopharmaceuticals; Retrospective Studies; Risk Assessment; Single Photon Emission Computed Tomography Computed Tomography; Tarsal Bones; Technetium Tc 99m Medronate; Young Adult

Foot pain in pediatric patients often presents as a diagnostic challenge. Studies in adults with foot pain have shown that bone scans are valuable diagnostic tools, especially in instances in which clinical evaluation and conventional radiography have failed to provide a clear answer. To our knowledge, no similar investigation has ever been conducted in the pediatric population. The objective of this study was to determine the utility of bone scans as a diagnostic tool for children with foot pain of unclear etiology. Our secondary objective was to determine whether obtaining a bone scan, in fact, alters the treatment plan of such patients. Chart review was done, documenting the prebone scan versus post bone scan diagnosis and treatment plans. We found that bone scans were diagnostically useful in 38 of 49 [77.6%, 66-87, 90% confidence interval (CI)] cases, helping to establish new diagnoses in 31 of 49 (63%, 51-75, 90% CI) cases, and directing the treatment of children with clinically unclear foot pain in 31 of 49 (63%, 51-75, 90% CI) cases. We conclude that children between the age of 2 and 11 years who present with unilateral or bilateral foot pain of unclear clinical etiology, with a normal or inconclusive radiograph and physical examination, and who had no previous magnetic resonance imaging and/or computed tomography scan, may benefit from the use of a bone scan to guide diagnosis and treatment.

Topics: Bone and Bones; Child; Child, Preschool; Female; Foot Diseases; Humans; Male; Pain; Technetium Tc 99m Medronate; Tomography, Emission-Computed

Topics: Aged; Cutaneous Fistula; Female; Foot Bones; Foot Diseases; Humans; Hyperemia; Mycetoma; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Medronate

Topics: Adult; Anti-Inflammatory Agents; Fasciitis; Foot Diseases; Humans; Male; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Medronate

Bone scintigraphy is requested as part of the investigation of foot pain, but its contribution to clinical management has not been comprehensively documented. Previously published data are limited; the most comprehensive series identified scintigraphic abnormalities in patients with primarily orthopaedic problems and a control group was not included (Maurice HD et al. J Bone Joint Surg 1987;69B:448 52). The aim of this study was to evaluate whether bone scintigraphy may be useful in different clinical circumstances indicated by referral request details. Regions of scintigraphic abnormality were scored and compared with clinical details drawn from case notes of 60 patients with foot pain. The commonest clinical indications for scans were: confirmation of the clinical suspicion of plantar fasciitis, documentation of the extent of inflammatory arthritis and location of focal pathology. A group of 30 asymptomatic, age- and sex-matched controls were also studied. In 14 out of 19 symptomatic feet in the plantar fasciitis group, focal uptake at the medial calcaneal tubercle was present, confirming the diagnosis. In patients with non-specific, diffuse foot pain, the bone scan identified focal abnormalities in 11 out of 14 cases, thus directing the clinician to the site of pathology. Scintigraphy also proved useful in mapping local inflammatory disease. Technetium-99m methylene diphosphonate image abnormalities occurred in the control group most commonly in the midfoot (16 regions in 13 subjects) and first metatarsophalangeal joint (19 regions in 14 subjects).

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Arthritis; Bone and Bones; Female; Foot Diseases; Humans; Male; Middle Aged; Pain; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Medronate

Topics: Child, Preschool; Foot Diseases; Humans; Male; Osteochondritis; Radionuclide Imaging; Radiopharmaceuticals; Tarsal Bones; Technetium Tc 99m Medronate

The classical presentation of acute reflex sympathetic dystrophy (RSD) or triple-phase bone scintigraphy usually consists of increased periarticular uptake in each phase. The authors present a rare case of acute adult RSD characterized by bone hypofixation of Tc-99m MDP. Reflex sympathetic dystrophy in adults and children is reviewed.

Topics: Adult; Ankle; Female; Foot; Foot Diseases; Foot Injuries; Humans; Radionuclide Imaging; Reflex Sympathetic Dystrophy; Technetium Tc 99m Medronate

To evaluate distribution and intensity of 99mTc-methylene diphosphonate (99mTc-MDP) uptake in the navicular area in horses with forelimb lameness isolated to the palmar aspect of the foot.. Prospective, case-controlled study.. 7 horses with clinical signs of navicular syndrome and 7 control horses.. Palmar view, soft tissue-phase scintigraphic images of the foot were obtained between 7 and 12 minutes after injection of 120 to 170 mCi of 99mTc-MDP. Lateral and palmar view, bone-phase images were obtained at 30 minutes and 1, 2, and 4 hours after injection. Palmar views were evaluated by determining the ratio of image density in the navicular area to mean image density in the distal phalangeal area. Palmar and lateral view, bone-phase images were also scored on the basis of navicular area intensity (intense = 3, moderate = 2, mild = 1, and no uptake = 0). Density ratios and mean scores were evaluated as a three-way ANOVA.. Mean navicular-to-distal phalangeal density ratio for affected horses (1.77) was significantly (P = 0.003) greater than that for control horses (0.97). The mean subjective score for affected horses when evaluating palmar views only (1.85) and when evaluating palmar and lateral view pairs together (1.99) was significantly (P < 0.01) higher than scores for control horses (0.51, 0.62). Images obtained 1 hour after injection were as good at differentiating affected from control horses as images obtained between 2 to 4 hours after injection.. A substantial number of horses with palmar foot pain have increased scintigraphic uptake within the navicular bone 1 to 4 hours after injection of 99mTc-MDP. Lateral view, bone-phase images are less sensitive than palmar view, bone-phase images in revealing navicular area uptake.. A combination of lateral and palmar view scintigraphic images obtained between 1 and 4 hours after injection of 99mTc-MDP is a useful diagnostic aid in evaluating navicular bone involvement in horses with forelimb lameness isolated to the palmar aspect of the foot.

Topics: Analysis of Variance; Animals; Foot; Foot Diseases; Forelimb; Gait; Gamma Cameras; Horse Diseases; Horses; Movement Disorders; Radionuclide Imaging; Reference Values; Technetium Tc 99m Medronate; Tissue Distribution

Sarcoidosis is rarely recognized as an osseous manifestations alone. Patients with osseous involvement usually have a chronic multivisceral form of the disease. The authors report a case of osseous sarcoidosis without other visceral involvement. A bone scan was requested to evaluate the extent of the bone involvement and explore buttocks pain.

Topics: Arthralgia; Bone Diseases; Buttocks; Chronic Disease; Foot Diseases; Hand; Humans; Male; Middle Aged; Pain; Radionuclide Imaging; Sacroiliac Joint; Sarcoidosis; Technetium Tc 99m Medronate

Plantar fasciitis is a common cause of heel pain. We evaluated scintigraphic localisation of the inflammatory focus in 15 patients with this condition. Technetium-labelled bone scans precisely localised abnormal discrete areas of tracer uptake in 12 (80%) of patients in the medial and posterior aspect below the inferior surface of the calcaneum. Steroid injection at the inflammatory site abolished local tenderness and reduced pain in all 12. Our findings support an injection approach through the medial heel border posterior to the point of heel tenderness. Technetium scintigraphy may be a useful investigation to localise the steroid injection site in resistant cases of plantar fasciitis.

Topics: Fasciitis; Foot Diseases; Heel; Humans; Injections; Radionuclide Imaging; Steroids; Technetium Tc 99m Medronate

Dermatofibrosarcoma protuberans occurs early in life, is an unusual soft tissue tumor, and is uncommonly seen distal to knees. The authors present a rare case of dermatofibrosarcoma protuberans of the toe with different imaging modalities.

Topics: Adult; Bone and Bones; Dermatofibrosarcoma; Female; Foot Diseases; Gallium Radioisotopes; Humans; Magnetic Resonance Imaging; Radionuclide Imaging; Skin Neoplasms; Technetium Tc 99m Medronate; Thallium Radioisotopes; Toes

Topics: Adolescent; Crutches; Female; Foot Diseases; Humans; Radionuclide Imaging; Reflex Sympathetic Dystrophy; Technetium Tc 99m Medronate

To assess the role of magnetic resonance imaging (MRI) in diagnosing osteomyelitis in diabetic foot infections, 47 diabetic patients with clinical suspicion of osteomyelitis, nonhealing foot ulcer, or soft tissue infection of the foot were examined prospectively by MRI and plain radiographs. Pathological confirmation of diagnosis was obtained in 62 bones from 32 patients. In addition, 14 patients with pathological confirmation of diagnosis underwent technetium-99 MDP triple-phase bone and gallium-67 citrate scans. MRI was significantly more sensitive and accurate (P < .01), with equal specificity in comparison to plain radiographs and technetium and gallium scans. MRI also provided a more detailed and accurate depiction of the anatomy. At early clinical follow-up, complete resection of abnormal bone on an MRI scan correlated with clinical healing. In summary, MRI is indicated when plain radiographs are negative for osteomyelitis or when the extent and accurate depiction of the infective process will facilitate surgical planning.

Topics: Adult; Aged; Aged, 80 and over; Diabetes Complications; Female; Foot Diseases; Gallium Radioisotopes; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Osteomyelitis; Prospective Studies; Technetium Tc 99m Medronate

Osteomyelitis of the foot is a well-known complication of diabetes mellitus. In this study, the validity of 111In-labeled human nonspecific immunoglobulin G (IgG) scintigraphy was studied in 16 diabetic patients with foot ulcers, gangrene or painful Charcot joints. In all patients, plain radiographs, conventional bone scan images and 111In-IgG images were recorded. The results were verified by histologic examination of surgical specimens in patients who did not respond to antibiotic treatment within 2-3 wk (10 lesions) or long-term clinical follow-up of at least 6-mo (16 lesions). On the bone scans, all seven osteomyelitic foci were detected. However, 19 additional foci not due to osteomyelitis were seen. The absence of true-negative bone scans in this study resulted in a specificity of 0%. On the plain radiographs, four of seven osteomyelitis foci were detected; for 111In-IgG scintigraphy, six of seven (sensitivity 57% and 86%, respectively). Plain radiographs correctly ruled out osteomyelitis in 15 of 19 lesions, 111In-IgG scintigraphy in 16 of 19 (specificity 79% and 84%, respectively). All imaging procedures gave false-positive results in penetrating ulcers over the calcaneus in two patients and in one patient with a Charcot joint, most likely due to recent fractures. A false-negative 111In-IgG study was observed in a patient with severe arterial angiopathy. Accurate estimation of probable osteomyelitis was not possible from the results of soft-tissue cultures, since in only 6 of 12 positive cultures, osteomyelitic foci could be proven. Indium-111-IgG scintigraphy can contribute to adequate evaluation of osteomyelitis in diabetic foot complications because it improves specificity when compared to bone scan and radiographic findings and improves sensitivity in comparison to plain radiographs.

Topics: Adult; Aged; Aged, 80 and over; Arthropathy, Neurogenic; Diabetes Complications; Diagnosis, Differential; Female; Foot Diseases; Foot Ulcer; Gangrene; Humans; Immunoglobulin G; Indium Radioisotopes; Male; Middle Aged; Osteomyelitis; Radionuclide Imaging; Sensitivity and Specificity; Technetium Tc 99m Medronate

To establish strict clinical criteria for reflex sympathetic dystrophy (RSD) of the foot and to characterize any associated scintigraphic pattern, the authors performed three-phase radionuclide bone scanning in 51 patients prospectively referred because RSD was a diagnostic consideration. To establish sensitivity and specificity data, the cases of an additional 100 consecutive patients referred for a variety of foot problems were retrospectively reviewed. The authors defined RSD of the foot as a pain syndrome characterized by diffuse nonanatomic, often unrelenting pain; autonomic-vasomotor signs including warm or cool skin temperatures and moist-sweaty or dry-scaly skin; and a positive response to a lumbar sympathetic block. Patients with RSD have a characteristic delayed bone-scan pattern consisting of diffuse increased tracer throughout the foot, with juxta-articular accentuation of tracer uptake. Overall, sensitivity in this study was 100%; specificity, 80%; positive predictive value, 54%; and negative predictive value, 100%. False-positive images were obtained in patients with infection, diabetes, and chronic pain. Specificity was 66% in the subgroup of patients who underwent sympathetic block, with a positive-predictive value of 88%. There were no differences in scan pattern related to duration of symptoms prior to imaging.

Topics: Adult; Aged; Bone and Bones; False Positive Reactions; Female; Foot Diseases; Humans; Male; Middle Aged; Prospective Studies; Radionuclide Angiography; Reflex Sympathetic Dystrophy; Retrospective Studies; Technetium Tc 99m Medronate

The noninvasive diagnosis of osteomyelitis of the foot in diabetic patients with currently available radiologic and radionuclide imaging techniques is often difficult. Recently, 111In-labeled leukocyte scintigraphy has been proposed as an attractive alternative. Accordingly, we retrospectively reviewed 51 111In-labeled leukocyte scans, 49 technetium-99m bone scans, and 49 plain radiographs obtained in 51 adults with diabetes in whom osteomyelitis of the foot was suspected. The sensitivity and specificity of these techniques were evaluated in all patients, as well as in a subgroup of 11 patients with neuroarthropathy. Results with 111In-labeled leukocyte scans were also examined in subsets of patients with soft-tissue ulcers (n = 35) and those receiving antibiotics during investigation (n = 20). Confirmation or exclusion of osteomyelitis was made surgically in 28 patients and clinically in 23. Fourteen patients had osteomyelitis. Bone scans were most sensitive (93%) but least specific (43%); plain radiographs were most specific (83%) but least sensitive (43%). 111In-labeled leukocyte scans were both sensitive (79%) and specific (78%), and remained useful in patients with neuroarthropathy, soft-tissue ulcers, and antibiotic treatment. Poor spatial resolution contributed to the false-negative and false-positive 111In-labeled leukocyte scans, suggesting that this technique should not be interpreted independent of other tests. 111In-labeled leukocyte scans are a valuable diagnostic tool for the diagnosis of pedal osteomyelitis in diabetic patients.

Topics: Adult; Aged; Aged, 80 and over; Diabetes Mellitus, Type 1; Diabetes Mellitus, Type 2; Female; Foot Diseases; Humans; Indium Radioisotopes; Leukocytes; Male; Middle Aged; Osteomyelitis; Predictive Value of Tests; Radiography; Radionuclide Imaging; Retrospective Studies; Sensitivity and Specificity; Technetium Tc 99m Medronate

Diagnosis of osteomyelitis of the foot in diabetic patients may be difficult because of the coexistence of chronic cellulitis, vascular insufficiency, and peripheral neuropathy. This study compared the diagnostic accuracies of plain films, bone scans, and MR imaging studies in diabetic patients with suspicion of osteomyelitis of the foot. Twenty-nine plain radiographs, 20 bone scans, and 30 MR studies were obtained in 24 patients. Twenty-nine bones from 14 patients were pathologically proved either positive (25 bones) or negative (four bones) for osteomyelitis. Another 15 bones (10 patients) studied with MR had no pathologic proof, but the bones healed with only local wound care and/or a short course of oral antibiotics. These patients had trauma, cellulitis, or unhealed ulcers. The sensitivity and specificity of plain films were both 75%. Bone scans had a very low specificity (100% false-positive rate). A negative bone scan should strongly exclude the probability of osteomyelitis. Unlike the findings in previous reports, MR had much higher sensitivity and specificity than bone scans in detecting osteomyelitis in diabetic patients. When the 10 patients without pathologic proof (those who presumably had neuroarthropathy, vascular insufficiency, and/or cellulitis) were included, the sensitivity and specificity of all three techniques decreased. Our experience with this small group of patients suggests that MR is a useful imaging technique for diagnosing osteomyelitis of the foot in diabetic patients.

Topics: Adult; Aged; Diabetes Mellitus, Type 1; Diabetic Neuropathies; Female; Foot; Foot Diseases; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Osteomyelitis; Radiography; Radionuclide Imaging; Sensitivity and Specificity; Technetium Tc 99m Medronate

The authors reviewed the three-phase bone scans and radiographs of 24 patients with suspected pedal osteomyelitis who also had histologic confirmation of the diagnosis. Twenty patients had a pedal ulcer, cellulitis, or necrosis. Sensitivity and specificity of bone scanning were 70% and 43% respectively. Sensitivity and specificity of radiography were 70% and 50% respectively. The non-invasive diagnosis of pedal osteomyelitis remains problematic due to the poor specificity of bone scans and radiographs.

Topics: Adult; Aged; Cellulitis; Diagnosis, Differential; Female; Foot Diseases; Humans; Male; Middle Aged; Osteomyelitis; Osteonecrosis; Radiography; Radionuclide Imaging; Retrospective Studies; Skin Ulcer; Technetium Tc 99m Medronate

Six diabetic patients with roentgenographic finding of osteomyelitis, osteoarthropathy, or both, had combined leukocyte and bone imaging. Bone images demonstrated increased activity in all cases, including three without osteomyelitis. Leukocyte images, however, showed increased activity in only the three cases of osteomyelitis. There was minimal or no activity in the other three cases where osteoarthropathy was ultimately believed to be the basis of the roentgenographic and bone imaging changes.

Topics: Arthropathy, Neurogenic; Bone and Bones; Diabetic Neuropathies; Female; Foot Diseases; Humans; Indium Radioisotopes; Isotope Labeling; Leukocytes; Middle Aged; Osteomyelitis; Radionuclide Imaging; Technetium Tc 99m Medronate

Seventy-seven diabetic patients with suspected osteomyelitis of the foot were evaluated by three-phase bone scintigraphy (TPBS), indium 111-labeled white blood cell scintigraphy (WBCS), roentgenography, or some combination thereof. Retrospective analysis after clinical and pathologic follow-up indicated that the sensitivity of TPBS alone in the diagnosis of osteomyelitis was 100%, with a specificity of only 38% and an accuracy of 63%; the sensitivity of WBCS alone was 100%, with a specificity of 78% and an accuracy of 87%; and the combination of TPBS and WBCS yielded a sensitivity of 100%, with a specificity of 79% and an accuracy of 87%. Roentgenography yielded a sensitivity of 69%, with a specificity of 82% and an accuracy of 76%. The results of this study demonstrate that WBCS is superior to TPBS in the diagnosis of osteomyelitis in the diabetic foot, and TPBS adds little when viewed in conjunction with WBCS. Based on our observations and because of the high prevalence of neuropathic joint disease and other causes of false-positive bone scans, we believe that WBCS alone is adequate for evaluation of suspected pedal osteomyelitis in diabetic patients, particularly when the suspected lesion is located in the tarsometatarsal region in contrast to the toe region (7% vs 44% specificity and 28% vs 69% accuracy, respectively, for TPBS in these two regions, compared with 100% vs 68% specificity and 100% vs 80% accuracy, respectively, for WBCS in the same two regions).

Topics: Adult; Aged; Aged, 80 and over; Bone and Bones; Diabetes Complications; Female; Follow-Up Studies; Foot Diseases; Humans; Indium Radioisotopes; Leukocytes; Male; Middle Aged; Osteomyelitis; Predictive Value of Tests; Radionuclide Imaging; Retrospective Studies; Technetium Tc 99m Medronate

It is difficult to diagnose osteomyelitis in the presence of neurotrophic osteoarthropathy. We performed combined [99mTc]MDP bone scans and indium-111 (111In) leukocyte studies on 35 patients who had radiographic evidence of neuropathic foot disease and clinically suspected osteomyelitis. The [111In]leukocyte study determined if there was an infection and the bone scan provided the anatomic landmarks so that the infection could be localized to the bone or the adjacent soft tissue. Seventeen patients had osteomyelitis and all showed increased [111In]leukocyte activity localized to the bone, giving a sensitivity of 100%. Among the 18 patients without osteomyelitis, eight had no accumulation of [111In]leukocytes, seven had the [111In]leukocyte activity correctly localized to the soft tissue, two had [111In]leukocyte activity mistakenly attributed to the bone, and one had [111In]leukocyte accumulation in a proven neuroma which was mistakenly attributed to bone. These three false-positive results for osteomyelitis reduced the specificity to 83%. Considering only the 27 patients with a positive [111In]leukocyte study, the combined bone scan and [111In]leukocyte study correctly localized the infection to the soft tissues or bone in 89%. Uninfected neurotrophic osteoarthropathy does not accumulate [111In]leukocytes. We found the combined bone scan and [111In] leukocyte study useful for the detection and localization of infection to soft tissue or bone in patients with neuropathic foot disease.

Topics: Adult; Aged; Bone and Bones; Diabetic Neuropathies; Female; Foot Diseases; Humans; Indium Radioisotopes; Leukocytes; Male; Middle Aged; Osteomyelitis; Radionuclide Imaging; Technetium Tc 99m Medronate

Topics: Abscess; Foot Diseases; Humans; Kidney Diseases; Middle Aged; Radionuclide Imaging; Skin Ulcer; Technetium Tc 99m Medronate

When pain in the foot is difficult to localize and define, reflex sympathetic dystrophy should be considered as the possible diagnosis.

Topics: Female; Foot Diseases; Humans; Male; Middle Aged; Radionuclide Imaging; Reflex Sympathetic Dystrophy; Technetium Tc 99m Medronate

Two patients with Freiberg's infraction of the second metatarsal are presented. The scintigraphic pattern of a photopenic defect with hyperactive collar is demonstrated as evidence of the existence of avascular necrosis or infarction in this entity. The photopenia was appreciated only on pinhole collimator images in our first patient. The later revascularization phase of avascular necrosis with diffuse increase in uptake is demonstrated scintigraphically in the second patient.

Topics: Adolescent; Child; Female; Foot Diseases; Humans; Hyperemia; Metatarsus; Osteochondritis; Osteonecrosis; Radiography; Radionuclide Imaging; Technetium Tc 99m Medronate

Topics: Adult; Aged; Diphosphates; Diphosphonates; Female; Foot; Foot Diseases; Gallium Radioisotopes; Humans; Indium; Male; Middle Aged; Organometallic Compounds; Oxyquinoline; Radioisotopes; Radionuclide Imaging; Technetium; Technetium Tc 99m Aggregated Albumin; Technetium Tc 99m Medronate; Technetium Tc 99m Pyrophosphate; Thallium

In a patient with synovial sarcoma, routine bone survey showed no abnormality, while bone marrow scintigraphy with Tc-99m sulfur colloid revealed a defect in the fifth lumbar vertebra. At surgery, tumorous invasion was noted in the fifth lumbar vertebra and the surrounding tissues. It was suggested that the bone marrow scintigraphy was particularly useful in the detection of tumorous invasion into the bone marrow at the early stage before the destruction of skeletal tissue.

Topics: Adolescent; Bone Marrow; Diphosphonates; Foot Diseases; Humans; Lumbar Vertebrae; Male; Neoplasm Metastasis; Radionuclide Imaging; Sarcoma, Synovial; Spinal Neoplasms; Technetium; Technetium Tc 99m Medronate; Technetium Tc 99m Sulfur Colloid

Topics: Diabetic Neuropathies; Diagnosis, Differential; Diphosphonates; Foot Diseases; Gallium Radioisotopes; Humans; Osteomyelitis; Radionuclide Imaging; Skin Ulcer; Technetium; Technetium Tc 99m Medronate

The radionuclide bone scan is a noninvasive screening procedure which can help in identifying or confirming subtalar coalitions in patients with foot and/or ankle pain of unknown origin in whom routine plain film studies are inconclusive. Five patients (seven symptomatic feet) with clinical and plain film findings suggesting a subtalar coalition are presented. The radionuclide bone scans in four patients (six feet) with documented subtalar coalitions demonstrated augmented uptake in the subtalar joint in all six feet and a secondary area of augmented concentration in the superior aspect of the talus or talonavicular joint in five feet. The radionuclide bone scan was normal in the one patient who was later proved not to have a coalition. The scans of 100 patients with foot pain of other etiologies were reviewed, and in no instance did the scan demonstrate the combination of subtalar and talus or talonavicular uptake observed in the patients with coalitions.

Topics: Adolescent; Adult; Aged; Bone Diseases; Diagnosis, Differential; Diphosphonates; Foot Diseases; Humans; Male; Radionuclide Imaging; Talus; Technetium; Technetium Tc 99m Medronate