technetium-tc-99m-medronate and Fractures--Ununited

Many surgeons assess the biological activity of fracture nonunions by the presence or absence of callus on radiographs. However, the assessment of biological activity by radiographic appearance alone is controversial. Bone scintigraphy reflects blood flow and new bone formation; therefore, it is useful in assessing such biological activity in nonunion cases. This retrospective study compared radiographs with Tc-99m bone scintigraphy in 48 patients with uninfected nonunions. Positive uptake was observed in all cases. The uptake patterns were classified into 4 types: type 1, intense, uniform uptake; type 2A, a definite photon-deficient cleft between 2 areas of intense uptake; type 2B, a photon-deficient area other than type 2A; and type 3, an intermediate pattern with uneven, distributed uptake. The percentage of type 1 with intense uptake does not decrease with time, and type 2 does not increase. When uptake was compared in patients with a nonunion and a united fracture, higher uptake in nonunion was seen in 46% and lower uptake was seen in 27%. All cases of hypertrophic and more than half of oligotrophic nonunions were type 1. Type 2 was seen in 17% of oligotrophic, 67% of comminuted, 100% of defect, and 57% of atrophic nonunions. Poor callus visualization may not preclude biological activity. Long duration from injury may not equate to declines in biological activity. Comparing uptake in nonunions and united fractures in the same patient may help to assess biological activity. The photon-deficient area is helpful to assess the necessity of bone graft or other osteogenic supplementation.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Female; Fractures, Ununited; Humans; Male; Middle Aged; Radiography; Radionuclide Imaging; Radiopharmaceuticals; Retrospective Studies; Technetium Tc 99m Medronate; Young Adult

Intraoperative localization of rib abnormalities identified on bone scan can be deceptively difficult. Previously used techniques have had limited sensitivity and accuracy. The gamma probe can help localize these bone scan "hot spots.". Over the past 17 months, 5 patients underwent gamma-probe-directed limited rib resections following intravenous administration of Tc99m-MDP. Three patients required biopsies for suspected malignancy, and the other 2 underwent therapeutic resections for pain. The device was easy to work with following minimal training.. Localization was excellent, limiting the extent of surgery needed. Comparison with rib counting and preoperative bone scan localization showed a discrepancy of up to 13 cm. Sensitivity and accuracy were each 100%.. The gamma probe offers a simple and significant advance in the performance of rib biopsies for nonpalpable lesions.

Topics: Biopsy; Bone Neoplasms; Fractures, Ununited; Gamma Cameras; Humans; Monitoring, Intraoperative; Pneumothorax; Radionuclide Imaging; Reproducibility of Results; Ribs; Sensitivity and Specificity; Technetium Tc 99m Medronate

The efficiency and accuracy of a functional imaging technique in the detection of ischemic osteopathy is reviewed over a 10-year period. The study includes 161 patients who had trauma, 101 patients who had suspected Perthes disease, 43 patients who had dysbarism, and 22 patients who had renal transplants on steroid immunosuppressive therapy. After intravenous injection of 7.7 MBq kg-1 Tc-99m HDP data were collected on all patients during the first 20 minutes, accretion rate functional images were produced, and static bone scans performed after 3 hours. All patients were followed up until a definitive diagnosis (clinical and radiologic) of avascular necrosis or osteochondritis was confirmed or denied. Of the 327 patients studied, 114 had positive accretion rate images and 213 negative accretion rate images. There were 8 false-positive scan results and 2 false-negative scan results. The overall predictive accuracy was 97% (disease prevalence 33%) with a sensitivity rate of 98% and a specificity rate of 96%. The authors conclude that the technique is a valuable predictive diagnostic indicator for ischemic osteopathies.

Topics: Barotrauma; Bone and Bones; Chronic Kidney Disease-Mineral and Bone Disorder; Femur Head Necrosis; Fractures, Ununited; Humans; Kidney Transplantation; Legg-Calve-Perthes Disease; Osteochondritis; Predictive Value of Tests; Radionuclide Imaging; Sensitivity and Specificity; Technetium Tc 99m Medronate

Topics: Adult; Carpal Bones; Cumulative Trauma Disorders; Female; Fractures, Stress; Fractures, Ununited; Humans; Magnetic Resonance Imaging; Male; Radionuclide Imaging; Technetium Tc 99m Medronate; Ulna Fractures; Wrist; Wrist Injuries; Wrist Joint

Topics: Adult; Calcinosis; Exostoses; Femoral Fractures; Fractures, Ununited; Humans; Knee; Knee Injuries; Male; Ossification, Heterotopic; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Medronate; Tomography, X-Ray Computed

The results of combined scintigraphy in which indium-111-labeled leukocytes and technetium-99m methylene diphosphonate were used were compared with the results of cultures of open bone at 102 sites of delayed union or non-union, to determine the effectiveness of this combination as a preoperative indicator of osteomyelitis. There were twenty-five true-positive, fifty-nine true-negative, eleven false-positive, four false-negative, and three indeterminate interpretations, yielding, for the diagnosis of osteomyelitis, a sensitivity of 86 per cent, a specificity of 84 per cent, an accuracy of 82 per cent, a positive predictive value of 69 per cent, and a negative predictive value of 94 per cent. There were few false-negative scans; false-positive results were most likely at a metaphyseal site adjacent to a joint in which there was post-traumatic arthropathy, at the site of a failed arthrodesis, and at the site of an unstable delayed union or non-union.

Topics: Adolescent; Adult; Aged; Child; False Positive Reactions; Female; Femoral Fractures; Fractures, Ununited; Humans; Indium Radioisotopes; Leukocytes; Male; Osteomyelitis; Radionuclide Imaging; Shoulder Fractures; Technetium Tc 99m Medronate; Tibial Fractures

The authors evaluate the reliability of combined indium-111-labeled white blood cell (WBC) and technetium-99m methylene diphosphonate (MDP) bone scan interpretations at sites of suspected periarticular osteomyelitis with radiographic evidence of adjacent traumatic arthropathy. A review of all orthopedic patients who underwent In-111 WBC-Tc-99m MDP scintigraphy over a 7-year period revealed a subset of 32 such cases that also included results of bone-biopsy cultures. Twenty-eight patients had a history of traumatic intraarticular injury, and four had periarticular fracture malunion or nonunion. Compared with intraoperative culture results, blinded In-111 WBC-Tc-99m MDP scan interpretations included four true-positive, 17 true-negative, and 10 false-positive results, and one false-negative result. The predictive values for positive and negative scans were 28% and 94%, respectively. A high prevalence of false-positive In-111 WBC-Tc-99m MDP scans may occur at periarticular sites of patients with associated traumatic arthropathy. This reduces the specificity of this technique for osteomyelitis, making culture confirmation of positive scans necessary. A negative scan is highly predictive of negative culture results at these sites.

Topics: Adult; Aged; Bone and Bones; False Positive Reactions; Female; Fractures, Bone; Fractures, Ununited; Humans; Indium Radioisotopes; Joints; Leukocytes; Male; Middle Aged; Osteomyelitis; Predictive Value of Tests; Radionuclide Imaging; Retrospective Studies; Sensitivity and Specificity; Technetium Tc 99m Medronate

Technetium-99m methylene diphosphonate (99mTc-MDP) bone scintigraphy was performed in 45 patients (42 male and 3 female) with established non-united fractures to predict the healing response to pulsing electromagnetic field stimulation therapy. The bone scans revealed 3 different scintigraphic patterns. The most frequent pattern was an increased uniform uptake of the tracer at the non-union site (group 1). The second pattern was increased activity at the bone ends with a photon-deficient area between the fracture sites (group 2a) or a generalized decrease in the radionuclide concentration in the region of bone fragments (group 2b). When the scintigraphic pattern did not fit either of the two patterns or when the presence of the cold area between the bone fragments could not be judged with certainty, it was called indeterminate (group 3). All patients underwent pulsing electromagnetic field stimulation. The healing rate was 87.5% and 42.8% in group 1 and group 3 patients, respectively. None of the group 2 patients had any evidence of healing, and they all underwent surgical exploration, revealing complicated non-unions. We conclude that 99mTc bone scintigraphy is a useful tool in determining complicated non-unions and selecting the proper therapy mode.

Topics: Adult; Electromagnetic Fields; Electromagnetic Phenomena; Female; Femoral Fractures; Fracture Healing; Fractures, Ununited; Humans; Humeral Fractures; Male; Radionuclide Imaging; Technetium Tc 99m Medronate; Tibial Fractures

Scintigraphy was used after injection of technetium-99m methylene diphosphonate (MDP) and indium-111-labeled white blood cells (WBCs) to assess for the presence of osteomyelitis in 97 patients who had undergone prior surgical procedures. Thirty-four patients with abnormal In-111-labeled WBC patterns underwent restudy with Tc-99m albumin colloid (AC). Scintigraphic findings were considered positive for osteomyelitis whenever localization of In-111-labeled WBCs exceeded Tc-99m AC activity in extent or focal intensity (discordant pattern). Ten of 12 patients with culture-proved osteomyelitis had discordant patterns; two had false-negative (concordant) patterns. The cases of 20 of 22 patients without infection who were considered to have osteomyelitis on the basis of patterns of In-111-labeled WBCs and Tc-99m MDP were reclassified correctly on the basis of concordant patterns of In-111-labeled WBCs and Tc-99m AC. Radiocolloid images improved the overall scintigraphic specificity for osteomyelitis from 59% without bone marrow imaging to 92%; sensitivity decreased from 94% to 88%.

Topics: Adolescent; Adult; Aged; Bone and Bones; Bone Marrow; Diagnostic Errors; Female; Fractures, Ununited; Humans; Indium Radioisotopes; Joint Prosthesis; Leukocytes; Male; Middle Aged; Osteomyelitis; Prospective Studies; Radionuclide Imaging; Sensitivity and Specificity; Technetium Tc 99m Medronate

Forty patients with fresh femoral neck fractures treated with closed reduction and internal fixation were included in a prospective study of nonunion and osteonecrosis by preoperative and postoperative scintimetry. Correlated roentgenographic follow-up studies were continued for two years postoperatively. The aim of the study was to determine the relative prognostic accuracy of preoperative versus postoperative scintimetry. A ratio between the radionuclide uptake over the femoral head on the fracture side and the contralateral side exceeding 1.9 at the preoperative scintimetry and 1.2 at the postoperative scintimetry was associated with a high incidence of union, whereas a lower ratio often predicted subsequent complications (redisplacement, nonunion, or late segmental collapse). Prognostic accuracy was higher for scintimetry of fractures treated with closed reduction and internal fixation (0.70) than for untreated fractures (0.53). These results suggest that scintimetry is useful postoperatively to complement roentgenographic examination in assessing the prognosis of femoral neck fractures.

Topics: Aged; Aged, 80 and over; Female; Femoral Neck Fractures; Follow-Up Studies; Fracture Fixation, Internal; Fractures, Ununited; Hip Prosthesis; Humans; Male; Manipulation, Orthopedic; Middle Aged; Postoperative Period; Predictive Value of Tests; Preoperative Care; Prognosis; Prospective Studies; Radiography; Radionuclide Imaging; Reoperation; Technetium Tc 99m Medronate

Forty-nine patients with 50 fracture nonunions 4-48 months after injury underwent technetium-99m methylene diphosphonate (99mTc-MDP) scintigraphy on day 1, combined 99mTc-MDP and indium-111 leukocyte (111In-WBC) scintigraphy on day 2, and gallium-67 (67Ga) scintigraphy on day 3. The results were compared to evaluate the relative abilities of these scintigraphic techniques to detect osteomyelitis. Nine patients had clinical evidence of infection at the time of imaging, and 40 patients (41 fractures) did not. Open-biopsy cultures were performed at all fracture sites and were positive at 21 (42%) of the 50 sites. Combined 99mTc-MDP/111In-WBC images were interpreted with the use of two criteria. A positive study by the first criterion required 111In-WBC localization in the region of the nonunion fracture. A positive study by the second criterion required 111In-WBC localization in bone at the fracture site. The first criterion yielded a sensitivity of 84%, specificity of 72%, and accuracy of 74%; the specificity improved to 97% with an accuracy of 88% when the second criterion was used. Ten (25%) of the 40 patients thought not to have osteomyelitis by clinical criteria at the time of imaging had true-positive 99mTc-MDP/111In-WBC studies by biopsy culture results. Gallium-67 studies were interpreted as nondiagnostic if localization of radioisotope at fracture sites was equal to that with 99mTc-MDP, positive if 67Ga localization was greater than that of 99mTc-MDP, and negative if it was less than that of 99mTc-MDP. Twenty-one 67Ga studies were interpreted as nondiagnostic; 11 (52%) of the 21 had culture-positive fracture sites. The accuracy of 67Ga/99mTc-MDP imaging was 39%. Combined 99mTc-MDP/111In-WBC imaging is useful in the detection of osteomyelitis at fracture nonunion sites and improves the specificity of 111In-WBC imaging by differentiating inflammation/infection in adjacent soft tissue from osteomyelitis at the fracture site. Gallium-67 with 99mTc-MDP imaging is not sufficiently reliable in this clinical setting to be useful as an indicator for osteomyelitis.

Topics: Adult; Aged; Female; Femoral Fractures; Fractures, Ununited; Gallium Radioisotopes; Humans; Humeral Fractures; Indium Radioisotopes; Leukocytes; Male; Middle Aged; Osteomyelitis; Prospective Studies; Radionuclide Imaging; Technetium Tc 99m Medronate; Tibial Fractures

A case of greatly increased blood flow in the region of a fracture with malunion of the left femur, both in the flow and immediate blood pool studies during three phase bone imaging, is presented. The sluggish left femoral artery flow resulted from the greatly increased regional perfusion and is similar to the findings in acute osteomyelitis. The sluggish left femoral artery flow and greatly increased regional perfusion of the site is probably best explained as a regional "neurovascular flush" resulting from the pain caused by the malunion of the fracture and/or hyperemia in the area of the malunion responding to inflammation.

Topics: Aged; Diagnosis, Differential; Femoral Fractures; Fractures, Ununited; Humans; Male; Osteomyelitis; Radionuclide Imaging; Technetium Tc 99m Medronate

The uptake of 99mTc-MDP was studied in 73 patients after a tibial fracture. The image obtained five minutes after injection during a period between one and four weeks after fracture was found to be related to the incidence of non-union after six months. A ratio of 1.3 between the uptake at the fracture site and at normal bone adjacent to it predicted non-union in an individual patient with a sensitivity of about 70% and a specificity of 90%.

Topics: Adolescent; Adult; Fractures, Ununited; Humans; Middle Aged; Predictive Value of Tests; Radionuclide Imaging; Technetium Tc 99m Medronate; Tibial Fractures; Time Factors; Wound Healing

Thirty-one femoral neck fractures which united without complications (nonunion or late segmental collapse) were included in a prospective sequential scintimetric study. Roentgenologically, three subgroups with different healing rates could be distinguished: rapid union, normal union, and delayed union. All fractures showed a rapid increase in relative femoral head radionuclide uptake after the 1-week scintimetry, followed by a gradual decline after 6 weeks-3 months. However, both the initial rise in activity and the time for maximal uptake tended to differ between the three groups. For rapid union and normal union the peak activity was registered at 6 weeks and for delayed union at 3 months. It is concluded that sequential scintimetric assessment of femoral head uptake can identify different healing rates and that this difference can be partly explained by a transient impairment of vascular supply to the femoral head in fractures with delayed healing.

Topics: Adult; Aged; Female; Femoral Neck Fractures; Fractures, Ununited; Humans; Male; Middle Aged; Prognosis; Prospective Studies; Radionuclide Imaging; Technetium Tc 99m Medronate; Time Factors; Wound Healing

Forty-five patients with recent cervical hip fractures were included in a prospective, clinical, radiographic and sequential scintimetric study. Striking changes in radionuclide uptake over the entire hip region on the fracture side were found during the first 5 postoperative months. Fractures that healed without complications showed the highest relative femoral head uptake at 1 week and a peak value at 6 weeks, followed by a gradual decline at the subsequent examinations. Fractures with complications (redisplacement, nonunion, or late segmental collapse) showed a lower initial uptake and a more gradual increase and only a slight tendency towards increased uptake after 3 months. The accuracy in predicting nonunion with scintimetric examination alone is high both at 1 and at 6 weeks, and the accuracy is almost equally high with combined scintimetric, radiographic, and clinical assessment 3-5 months postoperatively.

Topics: Aged; Female; Femoral Neck Fractures; Femur Head; Femur Neck; Follow-Up Studies; Fractures, Ununited; Hip; Humans; Male; Prognosis; Prospective Studies; Radiography; Radionuclide Imaging; Technetium Tc 99m Medronate; Time Factors; Wound Healing

Topics: Aged; Diphosphonates; Fractures, Ununited; Humans; Male; Mandibular Fractures; Radionuclide Imaging; Technetium; Technetium Tc 99m Medronate; Wound Healing

Twenty-four patients with a history of post-traumatic fracture nonunion underwent sequential 99mTc and 67Ga citrate scintigraphy in an attempt to differentiate between posttraumatic fracture nonunion and nonunion complicated by subclinical osteomyelitis. Neither technetium nor gallium studies alone nor in combination, with or without clinical correlation, could help delineate between fracture nonunion and nonunion complicated by subclinical osteomyelitis because of the increased technetium and gallium radioisotope uptake associated with the nonunion site.

Topics: Adolescent; Adult; Aged; Diphosphonates; Female; Fractures, Ununited; Gallium Radioisotopes; Humans; Male; Middle Aged; Osteomyelitis; Prospective Studies; Radionuclide Imaging; Technetium; Technetium Tc 99m Medronate

In seven patients suffering redisplacement, nonunion or segmental collapse after nailing of femoral neck fractures, subsequent changes in the vitality of the femoral head were studied with tetracycline labeling and 99mTc-MDP scintimetry. At reoperation (total hip arthroplasty), the femoral heads were extracted and sawn into slices which were then analyzed. Vitality before nailing was totally lacking (tetracycline labeling) in one case (nonunion), and in the remaining cases moderate reduction was seen, most pronounced in the apical part of the head. In all cases, scintimetry 1-2 weeks after nailing showed reduced femoral head uptake of 99mTc-MDP, but scintimetry some hours before reoperation showed increased femoral head uptake. Isotope analysis of the slices from the extracted femoral heads showed marked reduction of uptake in the apical part of the head, moderate reduction in the distal and anterior parts, and satisfactory uptake in the posterior part of the head and the foveal region, though with individual variations. It was concluded that there is a genuine increase in uptake (revascularization) later in the course in postoperatively avascular heads, and that the apical part of the femoral head sustains the most pronounced vascular damage in femoral neck fracture and is probably the slowest to revascularize.

Topics: Aged; Diphosphonates; Femoral Neck Fractures; Femur Head; Fractures, Ununited; Hip Prosthesis; Humans; Radionuclide Imaging; Reoperation; Technetium; Technetium Tc 99m Medronate; Tetracycline

A scintimetric study using Tc-99m MDP was made of 54 patients with delayed union, nonunion, or late segmental collapse of the femoral head, 4-92 months after femoral neck fracture. In radiographically verified collapse, the radionuclide uptake ratio between the femoral head on the fractured and on the intact side (HHR) was significantly higher than in fractures resulting in delayed union or nonunion. On the basis of scintimetric and radiographic findings, the patients with healing disturbances could be divided into three groups, characterized by the following features: Satisfactory post-reduction position of the fracture without subsequent redisplacement and a high HHR, which as a rule turned out to be delayed union; The same radiographic pattern but with a lower HHR, which in most cases resulted in nonunion; Inadequate reduction or early redisplacement of the fracture with a high HHR, which resulted in nonunion. The fractional precision in discriminating between different types of disturbed fracture healing by means of skeletal scintimetry was 0.86 in this study. This non-invasive and technically simple method would therefore be a valuable complement to radiography in the assessment of healing, more than 4 months after fracture of the femoral neck.

Topics: Adult; Aged; Diphosphonates; Female; Femoral Neck Fractures; Fractures, Ununited; Humans; Male; Middle Aged; Radiography; Radionuclide Imaging; Technetium; Technetium Tc 99m Medronate; Time Factors; Wound Healing

Twenty-six patients with late complications following femoral neck fracture were examined with both skeletal and bone marrow radionuclide scintimetry. There was no correlation between the methods with respect to the quantitative assessment of femoral head vascularity based on different uptake ratios comparing the fractured and the intact side. Skeletal scintimetry always had good image quality and permitted reliable differentiation between nonunion of the fracture and late segmental collapse, in contrast to bone marrow scintimetry which gave poor image quality. Skeletal scintimetry thus seems superior to bone marrow scintimetry for assessment and differential diagnosis of late complications following femoral neck fracture. It is emphasized that the physiological mechanisms for radionuclide uptake must be taken into account when comparing scintimetric studies using different tracers.

Topics: Aged; Bone Marrow; Diagnosis, Differential; Diphosphonates; Female; Femoral Neck Fractures; Fractures, Ununited; Humans; Male; Middle Aged; Radionuclide Imaging; Technetium; Technetium Tc 99m Medronate; Technetium Tc 99m Sulfur Colloid; Time Factors

In 20 cases routine static bone scans were no value in the detection of delayed fracture healing. Using the 7.5-15 min net uptake of technetium labelled phosphate, disturbed fracture healing was detected in a series, of 37 cases. Normally healing fractures had an increase of 3 per cent per month and delayed unions less than half that amount. Non-unions had no net uptake.

Topics: Bone Transplantation; Diphosphates; Diphosphonates; Fracture Fixation; Fractures, Bone; Fractures, Ununited; Humans; Male; Radionuclide Imaging; Technetium; Technetium Tc 99m Medronate; Technetium Tc 99m Pyrophosphate; Tibial Fractures; Time Factors; Wound Healing