Use of SPECT-CT scans in diseases of the foot

NewsBot · Dec 29, 2012

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The diagnostic value of single photon-emission computed tomography bone scans combined with CT (SPECT-CT) in diseases of the foot and ankle
Vinay Kumar Singh , Sadaf Javed, Arum Parthipun, Andrea Helene Sott
Foot and Ankle Surgery; 29 December 2012

Background
A radionuclide bone scan with single photon-emission computed tomography and CT (SPECT-CT) is a new imaging modality which combines highly detailed CT with the functional information from a triple phase radionuclide bone scan. Little has been published about its diagnostic accuracy and usefulness in foot and ankle pathology. The aim of this study is to evaluate whether bone scans with SPECT-CT provide a useful contribution to the management of patients with foot and ankle pain, and whether it results in changes to clinical management.

Methods
A retrospective study involving 50 patients was conducted between March 2010 and April 2011. SPECT-CT was requested in cases where definitive clinical diagnosis could not be achieved after clinical examination and plain radiography. Pathology as highlighted on SPECT-CT was taken as the definitive diagnosis in these patients and was treated accordingly. Patients were subsequently seen in the follow up clinic to evaluate the outcome of their treatment.

Results
In 11 patients (22%), the provisional clinical diagnosis matched with the findings of the SPECT-CT and no change in treatment was necessary. In 39 patients (78%) the findings of the SPECT-CT did not correlate exactly with the initial clinical diagnosis and led to a modified treatment plan. The accuracy, sensitivity, specificity, positive predictive and negative predictive value of SPECT-CT in this series was 94%, 95.45%, 83.3%, 97.6% and 71.43% respectively.

Conclusions
SPECT-CT is a useful investigation tool in foot and ankle pathologies. The present study shows a high diagnostic accuracy and we recommend its use in cases with diagnostic uncertainty.
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Admin2 · Dec 29, 2012

Related Threads:
Forefoot inflammation/pain, Spect-CT shows cuboid uptake
Fewer Amputations in Diabetic Patients with Dual Isotope SPECT/CT

Single-photon emission computed tomography

Nuclear medicine tomographic imaging technique

SPECT image (bone tracer) of a mouse MIP

Collimator used to collimate gamma rays (red arrows) in a gamma camera

Single-photon emission computed tomography (SPECT, or less commonly, SPET) is a nuclear medicine tomographic imaging technique using gamma rays.^[1] It is very similar to conventional nuclear medicine planar imaging using a gamma camera (that is, scintigraphy),^[2] but is able to provide true 3D information. This information is typically presented as cross-sectional slices through the patient, but can be freely reformatted or manipulated as required.
The technique needs delivery of a gamma-emitting radioisotope (a radionuclide) into the patient, normally through injection into the bloodstream. On occasion, the radioisotope is a simple soluble dissolved ion, such as an isotope of gallium(III). Usually, though, a marker radioisotope is attached to a specific ligand to create a radioligand, whose properties bind it to certain types of tissues. This marriage allows the combination of ligand and radiopharmaceutical to be carried and bound to a place of interest in the body, where the ligand concentration is seen by a gamma camera.

^ SPECT at the U.S. National Library of Medicine Medical Subject Headings (MeSH)

^ Scuffham J W (2012). "A CdTe detector for hyperspectral SPECT imaging". Journal of Instrumentation. 7 (8). IOP Journal of Instrumentation: P08027. doi:10.1088/1748-0221/7/08/P08027. S2CID 250665467.

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NewsBot · Jun 13, 2013

Press Release:
Dual Agent Scan Differentiates Diabetic Foot Disorders

Novel approach to a molecular imaging technique helps doctors identify diabetic foot infection and rule out a non-infectious complication that develops in nerve-damaged joints

Vancouver, British Columbia – Researchers are kick-starting better diabetic foot care and promoting reduced radiation dose with a new take on a hybrid molecular imaging technique. By targeting both bone cell activity and immune response and improving imaging data interpretation, doctors can better distinguish diabetic foot infection from another common foot condition that often requires an additional bone-marrow scan for definitive diagnosis, say researchers presenting a study at the Society of Nuclear Medicine and Molecular Imaging’s 2013 Annual Meeting.

Diabetes, if not well managed, can damage blood vessels and nerves, causing poor circulation, reduced healing, a condition called neuropathy and loss of sensation, especially in sufferers’ feet. In time, infection can develop in soft tissues and spread to bone (osteomyelitis), and weight-bearing joints can degenerate in a condition called Charcot joint, named after the discoverer of the disease. This study reveals that with enhanced visual and data analysis of standard hybrid imaging that combines agents targeting bone cell activity and white blood cell immune response, physicians can accurately diagnose diabetic foot disorders and avoid second-day bone marrow imaging.

“Optimizing imaging protocol for detection and localization of diabetic foot conditions aids attending physicians in distinguishing between true bone infection and bone marrow overgrowth associated with Charcot joint,” says Sherif Heiba, MD, director of nuclear medicine residency program and associate professor of radiology at Mount Sinai School of Medicine, New York, NY. “This helps patients considerably by not only eliminating unnecessary scans but also reducing imaging time and the total radiation dose required to make that determination.”

Current imaging standards advise an additional bone marrow scan if initial scanning comes back positive for white blood cell activity in foot bone, indicating osteomyelitis but also possibly caused by hyperplasia, a proliferation of cells in the bone marrow of patients with Charcot joint. In this study, researchers investigated new data analysis for single photon emission computed tomography (SPECT) and computed tomography (CT), which together provide both biological and anatomical information about diabetic food disorders. The combination of imaging agents technetium-99mhydroxymethylene diphosphonate (HDP)—an expert biomarker for targeting bone—and a white blood cell or leukocyte biomarker that seeks out hot spots of infection can provide new comparative imaging data that make accurate diagnosis possible with a single scan.

A total of 22 diabetic patients were imaged with dual-isotope SPECT/CT for suspected diabetic foot infection. Scanning detected 27 lesions, 10 of which were confirmed as osteomyelitis. Osteomyelitis correlated with adjacent deep soft tissue infection in white blood cell SPECT/CT scan in nine of the 10 lesions. Researchers also analyzed patterns of wash-out of the white blood cell imaging agent to differentiate actual osteomyelitis from Charcot joint. Initial scans for 15 of the 17 lesions that were confirmed to represent Charcot joints showed white blood cell wash-out. Results were confirmed by an additional bone marrow scan, proving that dual-isotope bone and white blood cell SPECT/CT scan can positively identify osteomyelitis from Charcot joint without an additional bone marrow scan.

This study shows that accurate detection, differentiation and localization of foot disease with this molecular imaging technique can improve the lives of diabetic patients while simplifying the current imaging standard and reducing overall radiation exposure. Further investigation is needed to replicate these results in order to implement a change in standard imaging practice for diabetics with suspected foot infection.

An estimated 347 million people worldwide are currently living with diabetes, according to 2013 diabetes statistics from the World Health Organization. The highest rates of hospitalization due to diabetes complications relate tofoot infections that refuse to heal.

Scientific Paper 654: Sherif Heiba, Panagiotis Sideras, Lale Kostakoglu, Ina Savitch, Josef Machac, Radiology, Nuclear Medicine Division, Mount Sinai School of Medicine, New York, NY, “The beneficial influence of dual isotope SPECT/CT use on management of patients with suspected diabetic foot infection,” SNMMI’s 60th Annual Meeting, June 8–12, 2013, Vancouver, British Columbia.
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NewsBot · Jul 11, 2013

Dual-isotope SPECT/CT impact on hospitalized patients with suspected diabetic foot infection: saving limbs, lives, and resources.
Heiba S, Kolker D, Ong L, Sharma S, Travis A, Teodorescu V, Ellozy S, Kostakoglu L, Savitch I, Machac J.
Nucl Med Commun. 2013 Jul 7.

BACKGROUND:
Foot ulcer with suspected infection is one of the most common reasons for hospitalization and a major factor contributing to morbidity and high healthcare-related expenses among diabetic patients. Many patients will require amputation; however, major amputation is associated with an alarmingly high 5-year mortality rate. In this study, we assess the diagnosis and management of suspected foot infection in diabetic patients using dual-isotope (DI) single-photon emission computed tomography/computed tomography (SPECT/CT) compared with conventional imaging.
METHODS:
The diagnostic accuracy in and management of 227 patients who had undergone DI SPECT/CT was compared with that of 232 similar patients who had undergone conventional imaging including plain radiography, CT, planar bone scanning, planar indium-111 white blood cell scanning, and MRI. The duration of hospitalization was additionally compared between these two groups of patients after excluding patients with other active comorbidities.
RESULTS:
Soft-tissue infection, osteomyelitis with or without soft-tissue infection, and other bony pathologies were more accurately and confidently identified with DI SPECT/CT than with conventional imaging. DI SPECT/CT use was associated with significantly fewer major amputations and more selective bony resection as well as with shorter duration of hospitalization when compared with conventional imaging.
CONCLUSION:
In this large population of diabetic patients with suspected foot infection DI SPECT/CT was more accurate in diagnosing and localizing infection compared with conventional imaging. In addition, DI SPECT/CT provided clear guidance and promoted many limb salvage procedures. Of equal importance to health economics, DI SPECT/CT use was associated with considerably reduced length of hospitalization compared with conventional imaging.
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NewsBot · Mar 25, 2014

Assessing diabetic foot osteomyelitis remission with white blood cell SPECT/CT imaging.
Vouillarmet J, Morelec I, Thivolet C.
Diabet Med. 2014 Mar 21

AIMS:
Diabetic foot osteomyelitis is an important risk factor of lower limb amputation. Antibiotic therapy is often effective in preventing surgery. However, the duration of antibiotic therapy is difficult to define in the absence of a marker to diagnose osteomyelitis remission at the end of the treatment. In this study, we assessed the diagnostic performance of white blood cell SPECT/CT imaging for evaluating osteomyelitis remission.
PATIENTS AND METHODS:
Twenty-nine out of 42 episodes of diabetic foot osteomyelitis seen between December 2009 and April 2012 had radiographs, a three-phase bone scintigraphy and a white blood cell SPECT/CT at the end of antibiotic therapy. They were treated with antibiotics alone and considered in clinical remission. White blood cell SPECT/CT results were considered positive when abnormal uptake in the osteomyelitis location was identified. Osteomyelitis remission was defined by the absence of an osteomyelitis relapse after 12 months' follow-up.
RESULTS:
A negative white blood cell SPECT/CT was seen for 22 episodes of osteomyelitis. All of them were in remission. A positive white blood cell SPECT/CT was observed for seven episodes. A relapse occurred in five episodes (71.5%) after a median duration of 4 months (2-7 months). Sensitivity, specificity, positive predictive value and predictive negative value in predicting osteomyelitis relapse after the discontinuation of antibiotic treatment were, respectively, for radiographs 80%, 33%, 20% and 89%; for three-phase bone scintigraphy 100%, 12.5%, 15.5% and 100%; and for the white blood cell SPECT/CT 100%, 91.5%, 71.5% and 100%.
CONCLUSION:
Negative uptake on white blood cell SPECT/CT is a good marker for diagnosis of diabetic foot osteomyelitis remission and might be very useful in guiding antibiotic therapy. This article is protected by copyright. All rights reserved.
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NewsBot · Nov 22, 2014

Evaluation of acute Charcot foot using SPECT/CT imaging
A. Bilal, K. Boddu, S. Hussain, N. Mulholland, G. Vivian, M. Edmonds and V. Kavarthapu
Bone Joint J 2014 vol. 96-B no. SUPP 17 27

Introduction: Charcot arthropathy is a complex condition affecting diabetic patients with neuropathy. Diagnosis of acute Charcot arthropathy particularly in absence of any perceptible trauma is very challenging as clinically it can mimic osteomyelitis and cellulitis. Delay in recognition of Charcot arthropathy can result in gross instability of foot and ankle. Early diagnosis can provide an opportunity to halt the progression of disease. We report the role of SPECT /CT in the early diagnosis and elucidation of the natural progression of the disease.

Methods: Our multidisciplinary team analysed the scans of neuropathic patients presented with acute red, hot, swollen foot with normal radiological findings (Eichenholtz stage 0), attending the diabetic foot clinic from 2009–2013. The patients were selected from our database, clinic and nuclear medicine records. Initial workup included the assessment of peripheral neuropathy, temperature difference, between the feet, serum inflammatory markers and weight bearing dorsoplantar, lateral and oblique x-rays. All patients had three dimensional triple Phase Bone Scan using 800Mbq 99mTc HDP followed by CT scan. Those patients with obvious radiological findings and signs of infection were excluded.

Results: We evaluated 193 scans in 189 patients. One hundred and forty nine patients showed increase in focal radionuclide uptake at ligament insertion or subchondral bone with a positive predictive value of 77 percent. Forty four out of 193 were negative for Charcot changes and they were not treated as Charcot. These patients did not develop any Charcot changes in the mean follow up of 8 months, indicating a clinically false positive rate of 23%.

Conclusion: SPECT/CT scan is a highly sensitive and specific tool for early diagnosis and accurate localisation of Charcot neuroarthropathy as clinical examination results in high false positive rate. SPECT/CT also helps to understand the natural progression of this disease.
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NewsBot · Feb 14, 2015

Influence on Therapeutic Decision Making of SPECT-CT for
Different Regions of the Foot and Ankle
Leif Claassen, Theodor Uden, Max Ettinger, Kiriakos Daniilidis,
Christina Stukenborg-Colsman, and Christian Plaass
BioMed Research International; Volume 2014, Article ID 927576, 5 pages

Background. Single-photon emission computed tomography and computed tomography (SPECT-CT) has a high impact on
diagnosis and treatment decision of diferent joints. Te aim of this study was to evaluate whether there is a diferent gain of
SPECT-CT for diferent foot regions. Material and Methods. We retrospectively identifed 86 patients who received a SPECT-CT of
the foot and ankle between April 2011 and December 2012. We divided all patients into the following subgroups: ankle (group 1),
subtalar (group 2), Chopart (group 3), and Lisfranc (group 4). Te local ethical committee approved the study. Results. Te clinical
treatment decision was changed based on SPECT-CT results in 64.5% of group 1, 65.2% of group 2, and 75% each of groups 3 and
4. Eighty patients (93%) had pain relief afer treatment based on SPECT-CT. Te overall SPECT-CT sensitivity was 0.94 and the
specifcity was 0.57. Te positive and negative predictive values were 0.87 and 0.75, respectively. Conclusion. Te impact of SPECTCT
on treatment decision is slightly higher in diseases of the Chopart and Lisfranc joints than in the upper ankle and subtalar joints.
Te additional information has a clinical relevance due to the high rate of pain relief by treatment based on SPECT-CT diagnosis.
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NewsBot · Feb 14, 2015

Comparison of SPECT/CT and MRI in Diagnosing Symptomatic Lesions in Ankle and Foot Pain Patients: Diagnostic Performance and Relation to Lesion Type
Seunggyun Ha, Sung Hwan Hong, Jin Chul Paeng, Dong Yeon Lee, Gi Jeong Cheon, Amitabh Arya, June-Key Chung, Dong Soo Lee, …
PLOS x Published: February 10, 2015DOI: 10.1371/journal.pone.0117583

Purpose
The purpose of this study was to compare the diagnostic performance of SPECT/CT and MRI in patients with ankle and foot pain, with regard to the lesion types.

Materials and Methods
Fifty consecutive patients with ankle and foot pain, who underwent 99mTc-MDP SPECT/CT and MRI, were retrospectively enrolled in this study. Symptomatic lesions were determined based on clinical examination and response to treatment. On MRI and SPECT/CT, detected lesions were classified as bone, ligament/tendon, and joint lesions. Uptake on SPECT/CT was assessed using a 4-grade system. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of SPECT/CT and MRI were evaluated in all detected lesions and each lesion type. Diagnostic value of uptake grade was analyzed using receiver-operating characteristics (ROC) curve analysis, and diagnostic performance was compared using Chi-square or McNemar tests.

Results
In overall lesions, the sensitivity, PPV and NPV of SPECT/CT for symptomatic lesions were 93%, 56%, 91%, and they were 98%, 48%, 95% for MRI. There was no significant difference between SPECT/CT and MRI. However, the specificity of SPECT/CT was significantly higher than that of MRI (48% versus 24%, P = 0.016). Uptake grade on SPECT/CT was significantly higher in symptomatic lesions (P < 0.001), and its area under curve on ROC analysis was 0.787. In the analysis of each lesion type, the specificity of SPECT/CT was poor in joint lesions compared with other lesion types and MRI (P < 0.001, respectively). MRI exhibited lower specificity than SPECT/CT in bone lesions (P = 0.004) and ligament/tendon lesions (P < 0.001).

Conclusions
SPECT/CT has MRI-comparable diagnostic performance for symptomatic lesions in ankle and foot pain patients. SPECT/CT and MRI exhibit different diagnostic specificity in different lesion types. SPECT/CT may be used as a complementary imaging method to MRI for enhancing diagnostic specificity.
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NewsBot · Mar 12, 2015

Evaluation of 18F-Fluoride PET/MR and PET/CT in Patients with Foot Pain of Unclear Cause
Isabel Rauscher et al
J Nucl Med March 1, 2015 vol. 56 no. 3 430-435

Our objective was to compare the quality and diagnostic performance of 18F-fluoride PET/MR imaging with that of 18F-fluoride PET/CT imaging in patients with foot pain of unclear cause. Methods: Twenty-two patients (9 men, 13 women; mean age, 48 ± 18 y; range, 20–78 y) were prospectively included in this study and underwent a single-injection dual-imaging protocol with 18F-fluoride PET/CT and PET/MR. At a minimum, the PET/MR protocol included T1-weighted spin echo and proton-density fat-saturated sequences in 2 planes each with simultaneous acquisition of PET over 20 min. PET/CT included a native isotropic (0.6 mm) diagnostic CT scan (80 kV, 165 mAs) and a subsequent PET scan (2 min per bed position). By consensus, 2 masked interpreters randomly assessed both PET datasets for image quality (3-point scale) and for the presence of focal lesions with increased 18F-fluoride uptake (maximum of 4 lesions). For each dataset (PET/CT vs. PET/MR), the diagnoses were defined using both PET and a morphologic dataset. Standardized uptake values (SUVs) from the 2 devices were compared using linear correlation and Bland–Altman plots. Moreover, we estimated the potential for dose reduction for PET/MR compared with PET/CT considering the longer acquisition time of PET/MR analyzing count rate statistics. Results: Image quality was rated diagnostic for both PET datasets. However, with a mean rating of 3.0/3 for PET/MR and 2.3/3 for PET/CT, image quality was significantly superior for PET/MR (P < 0.0001). The sensitivity of the PET datasets in PET/MR and PET/CT was equivalent, with the same 42 lesions showing focal 18F-fluoride uptake. In PET/MR, the mean SUVmean was 10.4 (range, 2.0–67.7) and the mean SUVmax was 15.6 (range, 2.9–94.1). In PET/CT, the corresponding mean SUVmean of PET/CT was 10.2 (range, 1.8–55.6) and the mean SUVmax was 16.3 (range, 2.5–117.5), resulting in a high linear correlation coefficient (r = 0.96, P < 0.0001, for SUVmean and for SUVmax). A final consensus interpretation revealed the most frequent main diagnoses to be osteoarthritis, stress fracture, and bone marrow edema. PET/CT was more precise in visualizing osteoarthritis, whereas PET/MR was more specific in nondegenerative pathologies because of the higher soft-tissue and bone marrow contrast. The longer acquisition time of MR compared with CT would potentially allow 18F-fluoride dose reduction using hybrid 18F-fluoride PET/MR imaging of at least 50% according to the counting rate analysis. Conclusion: In patients with foot pain of unclear cause, 18F-fluoride PET/MR is technically feasible and is more robust in terms of image quality and SUV quantification than 18F-fluoride PET/CT. In most patients, 18F-fluoride PET/MR provided more diagnostic information at a higher diagnostic certainty than did PET/CT. Thus, PET/MR combines the high sensitivity of 18F-fluoride PET to pinpoint areas with the dominant disease activity and the specificity of MR imaging for the final diagnosis with the potential for a substantial dose reduction compared with PET/CT.
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NewsBot · Apr 16, 2015

Precise fusion of MRI and dual energy 111In WBC/99mTc HDP SPECT/CT in the diabetic foot using companion CT: an example of SPECT/MRI imaging.
Knešaurek K, Kolker D, Vatti S, Heiba S
The Quarterly Journal of Nuclear Medicine and Molecular Imaging [2015, 59(1):129-135]

AIM: The purpose of our study was to correctly fuse MRI and SPECT 111In WBC and 99m Tc HDP images using companion CT images. The fused images could be used to assess proper surgical approach in treatment of the diabetic foot. METHODS: Nine patients who had dual energy 111In WBC/ 99m Tc HDP SPECT/CT and MRI studies within a week were investigated in an ongoing project. A GE Infinia SPECT/CT camera and Siemens MAGNETOM 1.5T MR system were used in this study. First, the MRI and corresponding CT images were coregistrated using a transformation based on normalized mutual information. The transformation was saved and used for MRI and 111In WBC/ 99m Tc HDP SPECT fusion. A Jaszczak phantom study was also performed in order to estimate accuracy of MRI/ SPECT fusion.

RESULTS: The Jaszczak phantom study with 3.7 MBq 111In hot sphere showed that MRI/SPECT alignment using the approach described above produced registration with 0.7±0.4 mm accuracy in all three dimensions (3D). The nine clinical cases were visually evaluated and showed 1-2 mm 3D fusion accuracy. MRI provides almost perfect anatomy of soft tissue and bony structures but it may exaggerate the extent of infection. 111In WBC/99m Tc HDP SPECT imaging is more accurate for infection detection but lacks anatomical reference. Combination of these images proved an essential adjunct to diagnosis. A clinical utility of the approach is illustrated in two clinical examples.

CONCLUSION: The CT in dual energy 111In WBC/99m Tc HDP SPECT/CT studies can be used to accurately fuse and compare 111In WBC/99m Tc HDP SPECT and MRI images of the diabetic foot. This can significantly help in conservative treatment planning and limb salvage procedures in treatment of diabetic foot infections.
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NewsBot · Jul 14, 2015

99mTc-MDP bone SPECT/CT applications & scan appearances in ankle/foot pain: Pre and post-operative scenario
Gopinath Gnanasegaran, Ramin Mandegarin, Kanhaiyalal Agrawal, Sanjay Vijayanathan and Ignac Fogelman

Learning Objectives To review basic principles of 99mTc-MDP SPECT/CT & to review current literature on role of SPECT/CT in paints with ankle/foot pain To review the common clinical indications of 99mTc-MDP SPECT/CT To illustrate lesion localisation, characterisation and accurate diagnosis using SPECT/CT

Content Organisation Illustrated review of the 99mTc-MDP SPECT/CT appearances in patients with ankle/foot pain (talar osteochondral defect, stress fractures, sesamoditis, painful accessory bones, tarsal coalition, degenerative disease/ osteoarthritis) Illustrated review of the 99mTc-MDP SPECT/CT appearances in post operative ankle/foot pain (complete fusion, non-union, screw head OCD, fractures, degenerative disease) Illustrated review of the 99mTc-MDP SPECT/CT appearances in soft tissue injury (Achilles tendonitis, bursitis, plantar fasciitis etc) as the cause of pain Artefacts and technical challenges Summary - Major Teaching Points Radionuclide 99mTc-MDP SPECT/CT imaging is a useful diagnostic modality to localise and characterise painful ankle/foot pain in pre and post operative setting Radionuclide 99mTc-MDP SPECT/CT increases the diagnostic confidence and a useful modality and should be used routinely in the assessment of ankle and foot pain
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NewsBot · Jul 14, 2015

99mTc-MDP bone SPECT/CT applications & scan appearances in ankle/foot pain: Pre and post-operative scenario
Gopinath Gnanasegaran, Ramin Mandegarin, Kanhaiyalal Agrawal, Sanjay Vijayanathan and Ignac Fogelman

Learning Objectives To review basic principles of 99mTc-MDP SPECT/CT & to review current literature on role of SPECT/CT in paints with ankle/foot pain To review the common clinical indications of 99mTc-MDP SPECT/CT To illustrate lesion localisation, characterisation and accurate diagnosis using SPECT/CT

Content Organisation Illustrated review of the 99mTc-MDP SPECT/CT appearances in patients with ankle/foot pain (talar osteochondral defect, stress fractures, sesamoditis, painful accessory bones, tarsal coalition, degenerative disease/ osteoarthritis) Illustrated review of the 99mTc-MDP SPECT/CT appearances in post operative ankle/foot pain (complete fusion, non-union, screw head OCD, fractures, degenerative disease) Illustrated review of the 99mTc-MDP SPECT/CT appearances in soft tissue injury (Achilles tendonitis, bursitis, plantar fasciitis etc) as the cause of pain Artefacts and technical challenges Summary - Major Teaching Points Radionuclide 99mTc-MDP SPECT/CT imaging is a useful diagnostic modality to localise and characterise painful ankle/foot pain in pre and post operative setting Radionuclide 99mTc-MDP SPECT/CT increases the diagnostic confidence and a useful modality and should be used routinely in the assessment of ankle and foot pain
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NewsBot · Jul 28, 2015

Review of running injuries of the foot and ankle: clinical
presentation and SPECT-CT imaging patterns
Matthieu Pelletier-Galarneau et al
Am J Nucl Med Mol Imaging 2015;5(4):305-316

It is estimated that more than half of recreational runners will experience injuries related to the practice of their
sport. Three-phase bone scintigraphy is a very sensitive tool to identify sports injury, allowing imaging of hyperemia,
stress reaction, enthesopathy and fractures, often before abnormalities can be detected on conventional anatomical
modalities. In this article, we review the most common running related injuries and their imaging findings on
bone scintigraphy with SPECT-CT.
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NewsBot · Sep 5, 2017

Application of white blood cell SPECT/CT to predict remission after a 6 or 12 week course of antibiotic treatment for diabetic foot osteomyelitis
Julien Vouillarmet et al
Diabetologia 02 September 2017

Diabetic foot osteomyelitis is a major risk factor for amputation. Medical treatment allows remission in 53–82% of cases. However, the optimal duration of antibiotic therapy remains controversial as a validated marker of osteomyelitis remission is lacking. The aim of this cohort study was to assess prospectively the remission rate of diabetic foot osteomyelitis medically treated using white blood cell (WBC)-single-photon emission computed tomography (SPECT)/computed tomography (CT) as a predictive marker of remission.

Methods
Individuals with diabetic foot osteomyelitis that was non-surgically treated between April 2014 and December 2015 were included. All participants were treated with antibiotics alone. WBC-SPECT/CT was performed at 6 weeks and antibiotic treatment discontinued if the clinical signs of soft-tissue infection had resolved and there was no abnormal uptake of labelled WBCs. Treatment was otherwise continued for a total of 12 weeks and then discontinued. For these individuals, another WBC-SPECT/CT was performed at 12 weeks. Remission was defined as the absence of recurrence of osteomyelitis at the same location at 1 year.

Results
Forty-five individuals were included; overall remission rate was 84% at 1 year. A 6 week course of antibiotics was used in 23 participants, 22 of whom were in remission at 1 year (96%); a 12 week course was used for 22 participants, 16 of whom were in remission at 1 year (73%). Sensitivity of WBC-SPECT/CT at 12 weeks was 100%, specificity 56%, positive predictive value 46% and negative predictive value 100%.

Conclusions/interpretation
The study suggests that WBC-SPECT/CT could predict remission at the end of antibiotic treatment
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NewsBot · Mar 1, 2018

Diabetic Foot Infection: the role of PET/CT Imaging.
Arnon-Sheleg E et al
Curr Pharm Des. 2018 Feb 26. doi: 10.2174/1381612824666180227095439

Osteomyelitis in the diabetic foot can be difficult to diagnose and has serious consequences. Although 2-deoxy-2-[18F]-fluoro-D-glucose (FDG) positron emission tomography (PET) was traditionally used in oncology, it is emerging as a useful method in inflammatory and infectious entities. In this chapter, original research articles, meta-analyses, and reviews on the performance of FDG PET in diagnosing osteomyelitis in the diabetic foot will be discussed. In addition, PET available data in comparison to different imaging methods, different analysis methods, and impact of other co-existing conditions such as hyperglycemia, and long-term antibiotic treatment on the performance of FDG PET will be reviewed. Studies published in the last two decades showed variable performance of FDG PET in the assessment of diabetic foot infection with a relatively high specificity (67-93%) but a wide range of sensitivity (29-100%). More recent studies showed better sensitivity, probably due to improved imaging technology and analysis methods and use of hybrid imaging with positron emission tomography/computed tomography (PET/CT). FDG PET/CT has several advantages compared to other anatomical and functional imaging methods, including short acquisition time, high resolution, low radiation dose, and better tolerability. Further research is required to establish its role in the clinical practice.
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NewsBot · Sep 10, 2018

SPECT/CT in Postoperative Foot and Ankle Pain.
Kampen WU et al
Semin Nucl Med. 2018 Sep;48(5):454-468.

Postoperative pain is a clinically relevant issue in orthopedic patients, affecting more than 40% 1 year after foot and ankle surgery. Because of the very complex anatomy with many different joints and several motion axes, clinical examination and conventional imaging are sometimes not sufficient to identify a local pain generator. Local uptake of bone-seeking radiopharmaceuticals is known to correlate accurately with sites of pain generating foci and, thus, bone scintigraphy has been an established method to evaluate these respective patients for many years. However, the specificity is rather low if only planar images are acquired. The development of SPECT and especially of hybrid SPECT and CT imaging has significantly enhanced the specificity of this technique. The combination of both functional and morphological imaging, ideally performed with a dedicated SPECT/CT system to minimize misregistration owing to motion artifacts and to enhance image quality by attenuation correction, allows an early and reliable detection of pathologic bone processes, even in patients where radiological imaging with MRI or CT is hampered by metal implants. In diabetic patients with a neuropathic Charcot osteoarthropathy, infection can be differentiated from inflammatory bone alterations (causing bone marrow edema) almost certainly using SPECT/CT with radiolabeled white blood cells and antigranulocyte antibodies, allowing an individual and precise treatment planning either in the initial course of the disease or even after surgery. This article reviews the most frequent clinical challenges in patients after foot and ankle surgery, including a description of the various surgical procedures, the different imaging options with their advantages and disadvantages, and aims to integrate bone SPECT/CT into the clinical diagnostic workup.
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NewsBot · Dec 13, 2019

Bone SPECT/CT of the Foot and Ankle: Potential Clinical Application for Chronic Foot Pain
Ie Ryung Yoo
Nuclear Medicine and Molecular Imaging: 09 December 2019

Diseases of the foot and ankle are common but relatively difficult to diagnose because of the complexity of the anatomy and the frequent occurrence of multiple diseases at the same time. For these reasons, management of chronic foot pain is often clinically challenging. MRI is the imaging modality of choice in many types of diseases causing chronic foot pain, due to high resolution and excellent soft tissue contrast. However, in the postoperative state, the use of MRI can be limited by artifact from metallic devices, and it may be difficult to confirm whether the pathology detected on the MRI is the actual cause of the pain. As bone scintigraphy provides metabolic information, it can help to find the origin of pain, and SPECT/CT can further improve the specificity by adding anatomical information. In daily clinical practice for management of foot and ankle pathologies, the use of bone SPECT/CT is gradually increasing. However, there has been limited evidence of usefulness of SPECT/CT in evaluating chronic foot pain. In this review article, the potential application of bone SPECT/CT for chronic foot pain is illustrated, and the role of SPECT/CT in the management of the foot and ankle diseases in clinical practice is described.
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NewsBot · Oct 1, 2020

The added value of SPECT/CT in the Painful Foot and Ankle: a review of the literature
RobinEelsing et al
Foot and Ankle Surgery; 30 September 2020

Highlights
•SPECT/CT is useful in the diagnostic follow-up of foot and ankle pain when diagnosis on standard imaging modalities are inconclusive or when the patient has prolonged pain.
•SPECT/CT makes it possible to visualize pathologic processes and morphologic changes instead of just morphologic changes like in plain radiography, CT or MRI.
•Despite the use of SPECT/CT in the foot and ankle seems promising, this imaging technique is currently not used as much as it could be for diagnosing lesions of the distal parts of the lower extremities.
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Introduction
Foot and ankle injuries are common. Radiographic assessment is difficult because of the complex anatomy. In the past decade SPECT/CT made its introduction in assessing bone pathology, it combines both morphologic and pathologic imaging in one image aiming to increase sensitivity and specificity when compared with MRI or CT alone. The purpose of this review was to provide a literature overview on the diagnostic value of SPECT/CT in foot and ankle pathology.

Methods
A literature search was conducted in the databases of PubMed and EMBASE between January 2004 and September 2019 for articles describing the diagnostic value of SPECT/CT in foot and ankle pathology. For assessment of methodological quality of each study included in the analysis, QUADAS-2 checklist was used. Main outcomes were change of management, improved diagnosis and symptomatic improvement.

Results
A total of eight studies were identified describing the diagnostic value of SPECT/CT in foot and ankle pathology based on patient data. The combined analysis shows that change of management and improved diagnosis occurred in 48%-62% and 40-79% of the patients when compared with other imaging modalities and/or clinical assessment. Symptomatic improvement due to treatment based on SPECT/CT findings occurred in 92% of the patients.

Conclusion
SPECT/CT is useful when diagnosis based on other imaging modalities is inconclusive or when treatment based on these modalities does not lead to the desired symptomatic improvement.
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NewsBot · Nov 21, 2020

Bone scan with SPECT/CT in children with complex foot and ankle pain: Initial experience of a paediatric tertiary referral centre
James C Yeats et al
J Child Orthop. 2020 Oct 1;14(5):433-439

Purpose: This study was designed to review the diagnostic yield of single photon emission computed tomography-computed tomography (SPECT/CT) in children with complex foot/ankle pain.

Methods: We reviewed the records of 33 patients with complex foot and ankle pain referred for SPECT/CT (36 scans) performed between 1st September 2009 to 30th September 2019. All patients had foot and ankle radiographs and 18 out of 33 patients had undergone magnetic resonance imaging (MRI) prior to SPECT/CT. The diagnostic contribution of SPECT/CT was established at the time of the scan during a multi-disciplinary team meeting.

Results: The patients' mean age was 13.4 years (range six to 16.5 years) and 58% were female. In total, 18 patients had undergone previous surgical treatment. SPECT/CT was found to have decisive clinical value compared with radiographs and CT/MRI in 28 out of 36 cases. In ten patients it prompted surgical management (coalition excision, arthrodesis), in seven patients it redirected conservative management, in six patients it excluded other pathology and in five patients it showed additional/unexpected focal areas of mechanical stress, thus avoiding surgery. When compared with MRI, SPECT/CT added further clinical information in 13 out of 18 cases. SPECT/CT added decisive clinical value in five out of five patients with accessory ossicles, eight out of nine patients with tarsal coalition, five out of seven patients with surgically treated Congenital Talipes Equinovarus (CTEV) and four out of five patients with neuromuscular feet. In eight out of 36 cases SPECT/CT confirmed the diagnosis without adding significant information.

Conclusions: SPECT/CT can identify foci of active mechanical stress at cortical bone level in children with unexplained complex foot and ankle pain, particularly in the multiply operated foot, accessory ossicles and tarsal coalitions.
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NewsBot · Mar 20, 2021

Impact of SPECT/CT Imaging as Standard Workup for Foot and Ankle Osteoarthritis
Pustjens J et al
Clin Res Foot Ankle 2021, 9:3

Objectives: Determination of symptomatic osteoarthritis in the foot and ankle can be difficult. Due to the complex anatomy the
interpretation of clinical exam and conventional radiographs are often not reliable. SPECT/CT is a diagnostic modality which has
an upcoming role in diagnosing orthopaedic pathology. The primary aim of this study was to assess the additional value of SPECT/
CT when used routinely in patients with suspected foot and ankle osteoarthritis. Secondary aim was to assess intraobserver
reliability for both conventional workup and conventional workup combined with SPECT/CT.
Methods: In our clinic SPECT/CT imaging is obtained routinely in patients with suspected OA. Retrospectively 107 patients
who had suspected symptomatic OA and a SPECT/CT were included for analysis. All the clinical and radiological data were
randomized and blinded before being scored by one experienced orthopaedic surgeon. Based on conventional workup alone and
conventional workup combined with SPECT/CT a diagnosis and treatment plan was scored. The effect of SPECT/CT on clinical
decision-making was determined by the number of changes in diagnoses and treatment decisions. To assess intraobserver
reliability, data of 18 patients was added in twofold and scored twice by the same observer for conventional workup and for
SPECT/CT combined with standard workup. Intraobserver reliability was determined by calculating the kappa values.
Results: When SPECT/CT data was added to the conventional workup the diagnosis changed in 53%. In 26% of patients
addition of SPECT/CT data resulted in change of the original treatment plan. Intraobserver reliability for the conventional workup
was k=0.54 (moderate strength of agreement), compared to k=0.66 (substantial strength of agreement) when SPECT/CT data
were added.
Conclusion: This study demonstrates the impact of routine use of SPECT/CT imaging in patients with foot and ankle OA.
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NewsBot · Mar 25, 2021

The Added Value of Bloodpool SPECT/CT in Painful Non-Operated Foot and Ankle Undiagnosed With Standard Three-Phase Bone Scintigraphy
Cécile Cuvilliers et al
Front Med (Lausanne). 2021 Mar 5;8:634419

Purpose: To evaluate the interest of adding a bloodpool SPECT/CT to standard three-phase bone scintigraphy (BS) for etiological diagnosis of subacute and chronic lower extremity pains. Methods: We prospectively included patients addressed for pain of lower extremities lasting for at least 6 weeks, without previous surgery. They underwent a standard three-phase BS including late phase SPECT/CT, modified with an additional bloodpool SPECT/CT acquisition. Two independent physicians interpreted the images provided by both protocols. Diagnostic conclusion, diagnostic confidence, and interrater agreements were compared. Results: One hundred and eighteen lower extremities from 113 patients were analyzed (71 men, median age of 53 years). Adding bloodpool SPECT/CT to standard three-phase BS changed diagnostic conclusions in 24.6% (29/118) of lower extremities. The modified protocol revealed at least one diagnostic conclusion explaining the pain in 89% of extremities, rather than 83.1% with the standard protocol (p = 0.02). Tendinopathies were diagnosed in 12.7% of lower extremities, rather than 4.2% with standard BS (p = 0.002). Adding bloodpool SPECT/CT substantially increased overall confidence of each reader (p < 0.001). Inter-reader agreement was not significantly impacted. Conclusion: Adding bloodpool SPECT/CT to standard three-phase BS impacted diagnostic conclusion in a quarter of the patients with painful lower extremities, notably by revealing significantly more tendonitis.
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NewsBot · Dec 27, 2021

Diagnostic value of single-photon emission computed tomography-CT foot and ankle studies
Nirav Kaneria, Stewart Redman, David Little, Richard Graham
Nucl Med Commun. 2021 Dec 23

Aim: The aim of this study is to determine the impact of foot and ankle single-photon emission computed tomography (SPECT) CT on patient management.

Method and materials: A retrospective review over a 7-year period investigating whether the study identified or confirmed a source of symptoms. The electronic patient record was reviewed to see whether the test was helpful to the onward management of the patient.

Results: In total 44 patients were included and pathology was identified in 40 of the 44 patients, with four having normal studies. SPECT CT was deemed helpful in the management of 39 of the patients with the positive usefulness overall calculated as 89%. The remaining five patients where the test was not helpful have been discussed.

Conclusion: SPECT-CT is a helpful imaging test in the diagnosis of foot and ankle disorders with 89% of studies being diagnostically useful.
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NewsBot · Jan 26, 2022

The Value of SPECT-CT in Diagnosing Complex Non-Arthritic and Non-Neoplastic Conditions of the Foot and Ankle
Yaser Ghani, MBBS, BSc, FRCS (Tr&Orth), Ali-Asgar Najefi, FRCS (Tr&Orth), Alessio Bernasconi, FRCS (Tr&Orth), ...
Foot & Ankle Specialist
December 7, 2021

Introduction:

There is little information on the value of using single photon emission computerized tomography–computed tomography (SPECT-CT) in non-arthritic and non-neoplastic conditions of the foot and ankle (F&A). The vast majority of studies have investigated the role of SPECT-CT in degenerative conditions, bony pathology, and neoplastic conditions. The diagnostic value of SPECT-CT in purely non-arthritic and non-neoplastic conditions, in the absence of other conclusive radiological findings, is yet to be clarified. The aim of this study was to evaluate the value of SPECT-CT in a cohort of patients with complex F&A pathology, in whom diagnostic uncertainty existed after conventional imaging techniques, and to assess its added value in routine clinical practice.
Methodology:

A retrospective analysis of 297 SPECT-CTs from 2010 to 2017 found 18 SPECT-CTs (age = 16-56 years) performed for non-arthritic F&A pathology. Changes in diagnosis, management, and clinical outcome scores were recorded before and after SPECT-CT imaging.
Results:

The results demonstrated that the provisional diagnosis was different from the SPECT-CT diagnosis in 10 (56%) out of the 18 patients and led to a modified treatment plan, which was successful in 8 (80%) out of the 10 patients. The post-intervention Manchester Oxford Foot Questionnaire (MOX-FQ) and Visual Analogue Scale (VAS) score improved from 76 ± 18 to 58 ± 24 (P = .02), and from 72 ± 17 to 49 ± 32 (P = .01), respectively. The SPECT-CT scan was useful in confirming the provisional diagnosis in the remaining 8 patients where a diagnostic uncertainty existed after conventional imaging techniques. Overall, a total of 15 out of 18 patients (83%) showed an improvement in their symptoms after management led by SPECT-CT diagnosis.
Conclusion:

Our study highlights the added value of SPECT-CT in patients presenting with non-arthritic and non-neoplastic F&A conditions in which there is diagnostic uncertainty after conventional imaging. In 80% of cases, a change in management driven by the SPECT-CT findings led to a successful outcome. We have found SPECT-CT to be a useful investigative modality in assessing these complex F&A cases.
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NewsBot · Sep 12, 2023

The value of bone SPECT/CT in evaluation of foot and ankle arthrodesis and adjacent joint secondary osteoarthritis
Ujwal Bhure et al
Eur J Nucl Med Mol Imaging. 2023 Sep 7

Objective: To evaluate the value of SPECT/CT (single photon emission computed tomography/computed tomography) in foot and ankle arthrodesis and development of secondary osteoarthritis in the adjacent joints.

Materials and methods: SPECT/CT of 140 joints in the foot and ankle (34 upper ankle (UA), 28 lower ankle (LA), 27 talonavicular (TN), 12 calcaneo-cuboidal (CC), and 39 other smaller joints after arthrodesis in 72 patients were evaluated retrospectively regarding fusion grade in CT (0 = no fusion, 1 = < 50% fusion, 2 = > 50% fusion, 3 = complete fusion) and radiotracer uptake (0 = no uptake, 1 = mild uptake, 2 = moderate uptake, 3 = high uptake) on SPECT/CT. Severity of osteoarthritis (1 = mild, 2 = moderate, 3 = severe) and radiotracer uptake grade in adjacent joints was also assessed. In 54 patients, clinical information about interventions in the follow-up was available.

Results: According to the SPECT/CT, arthrodesis was successful (grade 2 or 3 CT fusion and grade 0 or 1 uptake) in 73% (25/34) of UA joints, 71% (20/28) of LA joints, 67% (18/27) TN, 100% (12/12) CC joints, and 62% (24/39) of other smaller joints. In 12 joints, there were discrepant findings in SPECT/CT (fusion grade 2 and uptake grade 2 or 3 (n = 9); or, fusion grade 0 or 1 and uptake grade 1 (n = 3)). The fusion rate 6-12 months after arthrodesis was 42% (14/33), 59% (20/34) after 13-24 months, and 89% (65/73) after more than 24 months, respectively. Average radiotracer uptake in arthrodesis decreased with age: 6-12 months: 1.60, 12-24 months: 1.32, > 24 months: 0.38. There was a significant negative correlation between radiotracer uptake grade and CT fusion grade. Osteoarthritis was observed in 131 adjacent joints. During the post scan follow-up, additional arthrodeses were performed in 33 joints, of which 11 joints were re-arthrodesis and 22 were new arthrodeses in osteoarthritic adjacent joints. All these 11 joints with failed arthrodesis had grade 0 of CT fusion and grade 2 or 3 of radiotracer uptake. All 22 adjacent joints with osteoarthritis, which subsequently underwent arthrodesis, had grade 2 or 3 radiotracer uptake, and the primary arthrodesis joints were healed and fused in all these cases.

Conclusion: Bone SPECT/CT is a valuable hybrid imaging tool in the evaluation of foot and ankle arthrodesis and gives additional useful information about the development of secondary osteoarthritis in the adjacent joints with higher value for the assessment of secondary osteoarthritis. A practical four-type classification ('Lucerne Criteria') combining metabolic and morphologic SPECT/CT information for evaluation of arthrodesis joints has been proposed.
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Use of SPECT-CT scans in diseases of the foot

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Perspectives toward feet, foot health, and footwear

X-ray Cassettes- 10" x 12" Spectroline- 2 new/5 used; Viking 10" x 12" film

Near Infrared Spectroscopy in peripheral artery disease and the diabetic foot

Is this a true Jones fracture? What are my prospects for recovery? How bad will the atrophy be?

Health professional perspectives on clinical outcomes in UK orthotic practice

Employment Prospect as Podiatric Surgeon?

Unsuspected Accessory Ossicle in Possible Sinus Tarsi Syndrome

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Use of SPECT-CT scans in diseases of the foot

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Single-photon emission computed tomography

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Perspectives toward feet, foot health, and footwear

X-ray Cassettes- 10" x 12" Spectroline- 2 new/5 used; Viking 10" x 12" film

Near Infrared Spectroscopy in peripheral artery disease and the diabetic foot

Is this a true Jones fracture? What are my prospects for recovery? How bad will the atrophy be?

Health professional perspectives on clinical outcomes in UK orthotic practice

Employment Prospect as Podiatric Surgeon?

Unsuspected Accessory Ossicle in Possible Sinus Tarsi Syndrome

Share This Page

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