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Diagnosing Infection in the Failed Joint Replacement: A Comparison of Coincidence Detection ¹⁸F-FDG and ¹¹¹In-Labeled Leukocyte/^99mTc-Sulfur Colloid Marrow Imaging

¹ Division of Nuclear Medicine, Long Island Jewish Medical Center, New Hyde Park, New York
² Department of Orthopedic Surgery, Long Island Jewish Medical Center, New Hyde Park, New York
³ Department of Orthopedic Surgery, North Shore University Hospital at Glen Cove, Glen Cove, New York

View larger version (83K): [in a new window]   FIGURE 1. 18F-FDG (left), WBC (middle), and marrow (right) images. (A) Infected 9-mo-old cemented left hip hemiarthroplasty. The only periprosthetic activity present on 18F-FDG image is at neck of femoral component, a nonspecific finding. Spatially incongruent activity (arrowheads) on WBC/marrow study is consistent with infection. (B) A 13-y-old hybrid right total hip prosthesis, with aseptic loosening of acetabular component. On 18F-FDG image, nonspecific periprosthetic activity is present along neck of femoral component and extends around acetabular component. Note similarity in appearance to that of infected hip prosthesis in A. WBC/marrow study is negative for infection. (C) There is nonspecific synovial activity on 18F-FDG image of infected 5-y-old cemented left total knee replacement. Femoral component was loose; tibial component was fixed. WBC/marrow study shows spatially incongruent distribution of activity in left knee, consistent with infection. (D) There is nonspecific synovial activity on 18F-FDG image of 10-y-old cemented left total knee replacement, with aseptic loosening of both femoral and tibial components. Uptake pattern is similar to that in C. WBC/marrow study is negative for infection.

View larger version (68K): [in a new window]   FIGURE 2. On 18F-FDG image (left), there is focal activity at distal tip of aseptically loosened femoral component (arrowhead) of 5-y-old left cemented total hip replacement. Similar focus is present on marrow image (right; arrowhead), indicating that activity on 18F-FDG image is due to marrow accumulation of tracer, not to infection. In at least some cases, periprosthetic activity on 18F-FDG images is due to marrow uptake of tracer.

View larger version (100K): [in a new window]   FIGURE 3. 18F-FDG (left), WBC (middle), and marrow (right) images. (A) On 18F-FDG image, there is BPI activity along lateral aspect of femoral component of infected 20-y-old cemented left total hip replacement. Both femoral and acetabular components were loose. Target-to-background ratio was 15.8, consistent with infection. Note extension of activity to lateral surface of thigh, corresponding to sinus tract. Spatially incongruent activity, also extending to thigh surface and consistent with infection, is present on WBC/marrow study. (B) On 18F-FDG image, BPI activity is present along lateral aspect of femoral component of 5-y-old cementless left total hip replacement with aseptic loosening of both femoral and acetabular components. Pattern is similar to that illustrated in A, but target-to-background ratio in this case was 3.0. WBC/marrow study is negative for infection. (C) Although there is linear area of soft-tissue activity in lateral thigh, there is no BPI activity on 18F-FDG image of infected 1-mo old hybrid left total hip replacement. Femoral and acetabular components of prosthesis were fixed. WBC/marrow study is consistent with infection.

View larger version (81K): [in a new window]   FIGURE 4. 18F-FDG (left), WBC (middle), and marrow (right) images. (A) On 18F-FDG image, there is BPI activity along tibial component (arrowheads) of infected 4-mo-old cemented left total knee replacement. Both components were loose. Target-to-background ratio was 5.2. WBC/marrow study is positive for infection. (B) On 18F-FDG image, BPI activity, less intense than that in A, is present around aseptically loosened tibial component (arrowheads) of 8-y-old cemented right total knee replacement. Femoral component was fixed. Target-to-background ratio was 3.7. WBC/marrow study, in which there is spatially congruent distribution of 2 tracers, is negative for infection.

View larger version (100K): [in a new window]   FIGURE 5. Radiographic (left) and 18F-FDG (right) images. (A) Femoral component of right hip hemiarthroplasty—which is, as radiograph illustrates, several centimeters long—appears as well-defined photopenic region with BPI activity along its lateral margin on 18F-FDG image. (B) Intramedullary components of this total knee replacement, as illustrated in radiograph, are considerably smaller than femoral component of hip prosthesis in A. Intramedullary stem of tibial component (arrowhead) is only about 2–3 cm in length, whereas intramedullary portion of femoral component (arrow) is only about 1 cm in length. Intramedullary stem of tibial component along with adjacent BPI activity (arrowheads) is identifiable on 18F-FDG image. Intramedullary part of femoral component cannot be identified (same patient as illustrated in Fig. 4B).