Sequential Tc-99m hydroxymethylene-diphosphonate (HDP) 3-phase bone (BS) and In-111 leukocyte scanning (WBCS) have been frequently used to evaluate the diabetic foot, as nonosteomyelitis BS uptake is repeatedly observed and osteomyelitis (OM) in WBCS is often uncertain without BS correlation. Additionally, both modalities are limited in lesion localization because of low resolution and lack of anatomic details. We investigated a method that combined BS/WBCS, and if needed, WBCS/bone marrow scanning (BMS) using SPECT/CT to accurately diagnose/localize infection in a practical protocol. Blood flow/pool images were obtained followed by WBC reinjection and next day dual isotope (DI) BS/WBCS planar and SPECT/CT. BMS/WBCS SPECT/CT (step 2 DI) was obtained on the following day when images were suspicious for mid/hindfoot OM. Diagnosis accuracy and confidence were judged for the various imaging combinations. Diagnosis was classified as OM, soft tissue infection (STI), both OM/STI, and other/no bony pathology by microbiology/pathology or follow-up. Distinction between various diagnostic categories and overall OM diagnostic accuracy in 213 patients were higher for DI than WBCS or BS alone, and for DI SPECT/CT than DI planar or SPECT only. Diagnostic confidence/lesion site was significantly higher for DI SPECT/CT than other comparative imaging methods. In a group of 97 patients with confirmed microbiologic/pathologic diagnosis, similar results were attained. Step 2 DI SPECT/CT performed in 67 patients further improved diagnostic accuracy/confidence. DI SPECT/CT is a highly accurate modality that considerably improves detection and discrimination of STI and OM while providing precise anatomic localization in the diabetic foot. This combined imaging technique promises to beneficially impact diabetic patient care.
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- Nuclear medicine and diabetic foot infections.Semin Nucl Med. 2009; 39: 52-65
- Osteomyelitis of the foot in diabetic patients: evaluation with plain film, 99mTc-MDP bone scintigraphy, and MR imaging.Am J Roentgenol. 1989; 152: 795-800
- Diagnostic accuracy of the physical examination and imaging tests for osteomyelitis underlying diabetic foot ulcers: meta-analysis.Clin Infect Dis. 2008; 47: 519-527
- Limitations of magnetic resonance imaging in the diagnosis of osteomyelitis underlying diabetic foot ulcers.Clin Infect Dis. 2009; 48: 135
- MR imaging of the diabetic foot.Radiol Clin North Am. 2004; 42: 61-71
- Osteomyelitis of the diabetic foot: MR imaging-pathologic correlation.Radiology. 1997; 203: 849-855
- Detection of osteomyelitis in the neuropathic foot: Nuclear medicine, MRI, and conventional radiography.Clin Nucl Med. 1998; 23: 77-82
- Value of a 24-hour image (four-phase bone scan) in assessing osteomyelitis in patients with peripheral vascular disease.J Nucl Med. 1985; 26: 711-717
- Osteomyelitis and soft-tissue infection: differential diagnosis with 24 hour/4 hour ratio of Tc-99m MDP uptake.Radiology. 1987; 163: 725-726
- Indium-111 leukocyte technetium-99m-MDP bone and magnetic resonance imaging: difficulty of diagnosing osteomyelitis in patients with neuropathic osteoarthropathy.J Nucl Med. 1990; 31: 549-556
- Combined bone scintigraphy and Indium-111 leukocyte scans in neuropathic foot disease.J Nucl Med. 1988; 29: 1651-1655
- Diagnosis of musculoskeletal infection using combined In-111 labeled leukocyte and Tc-99m SC marrow imaging.Clin Nucl Med. 1992; 17: 269-273
- Marrow versus infection in the Charcot joint: indium-111 leukocyte and technetium-99m sulfur colloid scintigraphy.J Nucl Med. 1998; 39: 346-350
- SPECT/CT.J Nucl Med. 2008; 49: 1305-1319
- Nuclear medicine imaging of diabetic foot infection: results of meta-analysis.Nucl Med Commun. 2006; 27: 757-764
- Added value of SPECT/CT in patients suspected of having bone infection: preliminary results.Arch Orthop Trauma Surg. 2007; 127: 211-221
- The value of SPET/CT in chronic osteomyelitis.Eur J Nucl Med Mol Imaging. 2003; 30: 1665-1673
- Usefulness of hybrid SPECT/CT in 99mTc-HMPAO–labeled leukocyte scintigraphy for bone and joint infections.J Nucl Med. 2006; 47: 1908-1913
- SPECT/CT using 67Ga and 111In-labeled leukocyte scintigraphy for diagnosis of infection.J Nucl Med. 2006; 47: 587-594
- Diabetic foot infection: usefulness of SPECT/CT for 99mTc-HMPAO-labeled leukocyte imaging.J Nucl Med. 2009; 7: 1042-1046
- The diabetic foot: initial experience with 18F-FDG-PET/CT.J Nucl Med. 2005; 46: 444-449
- Unsuspected osteomyelitis is frequent in persistent diabetic foot ulcer and better diagnosed by MRI than by 18F-FDG PET or 99mTc-MOAB.J Intern Med. 2008; 263: 99-106
- ACR appropriateness criteria on suspected osteomyelitis in patients with diabetes mellitus.J Am Coll Radiol. 2008; 5: 881-886
Published online: September 20, 2010
Financial Disclosure: None reported.
Conflict of Interest: None reported.
© 2010 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.