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2017, vol. 74, br. 7, str. 666-671
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Kombinovana scintigrafija kostiju sa 99mTc-MDP i 99mTc-ciprofloksacinom u razlikovanju aseptične nestabilnosti od infekcije periprotetskog tkiva zgloba kuka i kolena - preliminarna studija
Combined bone scintigraphy with 99mTc-MDP and 99mTc-ciprofloxacin in differentiation of hip and knee prosthesis aseptic loosening and infection: A preliminary study
aVojnomedicinska akademija, Institut za nuklearnu medicinu, Beograd bVojnomedicinska akademija, Institut za nuklearnu medicinu, Beograd + Univerzitet odbrane, Medicinski fakultet Vojnomedicinske akademije, Beograd cUniverzitet u Beogradu, Medicinski fakultet, Institut za ortopedsko-hirurške bolesti 'Banjica' dUniverzitet odbrane, Medicinski fakultet Vojnomedicinske akademije, Beograd + Vojnomedicinska akademija, Klinika za ortopedsku hirurgiju i traumatologiju, Beograd eUniverzitet odbrane, Medicinski fakultet Vojnomedicinske akademije, Beograd + Vojnomedicinska akademija, Klinika za endokrinologiju, Beograd
e-adresa: draganpucar@yahoo.com
Sažetak
Uvod/Cilj. Iako broj novo ugrađenih protetskih zglobova kuka i kolena svake godine raste, procenat neuspešnih artroplastika ostaje približno isti. Kao glavno pitanje nameće se, da li je u pitanju aseptična nestabilnost proteze ili je nestabilnost posledica neprepoznate infekcije. Cilj ove preliminarne studije je pokušaj da se kombinovanom upotrebom scintigrafije kostiju 99mTc obeleženim ciprofloksacinom i scintigrafije 99mTc-metilen-difosfonatom (MDP) unapredi dijagnostička tačnost razlikovanja aseptične nestabilnosti i periprotetske infekcije kod protetskih zglobova kuka i kolena. Metode. Kriterijum za ulazak u ovu studiju bio je: bol u protetskom zglobu, ograničeni pokreti u zglobu i uvećane vrednosti nespecifičnih znakova inflamacije, C-reaktivnog proteina i sedimentacije eritrocita. Ispitivanjem je obuhvaćeno 20 bolesnika sa 14 ugrađenih proteza kuka i 6 proteza kolena. Kod svih bolesnika učinjena je radiografija protetskog zgloba, kao i trofazna scintigrafija kostiju sa 99mTc-MDP. Tri do pet dana nakon scintigrafije kostiju urađena je i scintigrafija 99mTc-ciprofloksacinom sa određivanjem indeksa vezivanja. Infekcija periprotetskog tkiva je potvrđena mikrobiološkim nalazom. Rezultati. U 14 od 20 posmatranih protetskih zglobova potvrđena je infekcija, u pet slučajeva se radilo o aseptičnoj nestabilnosti protetskog zgloba, a u jednom slučaju simptomi nisu bili vezani za sam protetski zglob već je u pitanju bila loša biomehanika zgloba uzrokovana izrazitom slabošću abduktorne muskulature. Dobijena osetljivost i specifičnost za scintigrafiju kostiju pomoću 99mTc-MDP iznosila je 100% i 17%; za scintigrafiju 99mTc-ciprofloksacinom bila je 85,7% i 100%, a za kombinovani nalaz obe metode iznosila je 92,3% i 83,3%. Studija je potvrdila visoku negativnu prediktivnu vrednost scintigrafije kostiju u dijagnostici periprotetske infekcije. Drugim rečima negativna scintigrafija kostiju praktično isključuje mogućnost postojanja infekcije. S druge strane pozitivan nalaz scintigrafije kostiju ne može sa sigurnošću da potvrdi postojanje infekcije. Zaključak. Kombinacija dve metode, 99mTc-MDP scintigrafije kostiju sa scintigrafijom 99mTcciprofloksacinom znatno povećava mogućnost razlikovanja aseptične nestabilnosti i periprotetske infekcije zgloba.
Abstract
Background/Aim. Although the number of new primary implantation of hip and knee prostheses every year increases, the rate of failed arthroplasty is nearly the same. The main question is whether it is an aseptic instability or instability caused by infection. The aim of this preliminary study was an attempt with combined 99mTc-ciprofloxacin and 99mTc-methylene diphosphonate (MDP) bone scintigraphy to improve diagnostic accuracy in the differentiation of hip and knee prosthesis aseptic loosening and periprosthetic joint infection. Methods. Inclusion criteria of patients for this study were based on suspected periprosthetic joint infection: painful prosthetic joint, restricted joint movements and increased value of erythrocyte sedimentation rate or levels of C-reactive protein. We examined 20 patients with implanted 14 hip and 6 knee prosthesis. All patients also underwent plain radiography of suspected joint. In all patients, three-phase 99mTc-MDP bone scintigraphy was performed. Three to five days after the bone scan, we performed scintigraphy using 99mTc-ciprofloxacin with the calculation of accumulation index. Periprosthetic joint infection was confirmed on the basis of microbiological findings. Results. Periprosthetic joint infection was confirmed in fourteen of twenty observed joints, in five of them the aseptic loosening was present and in one patient's symptoms were not related to the prosthesis (poor biomechanics of prosthetic joints caused by weaknesses of muscle). Estimated sensitivity/specificity for 99mTc-MDP bone scintigraphy alone were 100/17%; for 99mTc-ciprofloxacin scintigraphy were 85,7/100%. Sensitivity and specificity were 92,3% and 83,3%, respectively for results obtained with combined assessment by both methods. Our study confirmed the high negative predictive value of 99mTc-MDP bone scan. The negative result of bone scan virtually excludes the possibility of periprosthetic infection. On the other hand, positive findings of 99mTc-MDP scintigraphy cannot with certainty confirm the infection. Conclusion. Combined 99mTc-MDP scintigraphy with 99mTc-ciprofloxacin scintigraphy significantly increases the ability of differentiation of aseptic loosening from periprosthetic joint infection.
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