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FDG PET for Differentiation of Infection and Aseptic Loosening in Total Hip Replacements: Comparison with Conventional Radiography and Three-Phase Bone Scintigraphy¹

¹ From the Department of Medical Radiology, Division of Nuclear Medicine, University Hospital, CH-8091 Zurich, Switzerland (K.D.M.S., E.M.K., T.F.H., G.W.G., G.K.v.S.); and Departments of Radiology (M.Z., J.H.) and Orthopaedic Surgery (H.P.N.), Orthopedic University Hospital Balgrist, Zurich, Switzerland. From the 2002 RSNA scientific assembly. Received December 11, 2002; revision requested February 7, 2003; final revision received August 5; accepted September 29. Address correspondence to K.D.M.S. (e-mail: katrin.stumpe@dmr.usz.ch).

View larger version (90K): [in a new window]   Figure 1. Images obtained in 76-year-old woman 26 months after left total hip replacement. Infection was diagnosed at microbiologic evaluation of a surgical specimen. Results of PET, serial conventional radiography, and bone scintigraphy were true-positive. A, Corrected and, B, uncorrected coronal FDG PET images show diffusely increased grade 3 FDG uptake (arrowheads) around the head and shaft of the left total hip replacement. The uncorrected image shows additional increased grade 3 uptake in the soft tissues (arrow) laterally adjacent to the prosthesis. C, D, Conventional anteroposterior radiographs of the left hip show rapid development of osteolysis (arrows) at the bone-prosthesis and cement-bone interfaces. D was obtained 6 months after C. E, F, Anterior bone scintigrams obtained during, E, the blood pool phase and, F, the late phase show diffusely increased radionuclide uptake (arrows) around the entire total left hip replacement. All images except C were obtained within 5 days of each other.

View larger version (133K): [in a new window]   Figure 2. Images obtained in 52-year-old man 15 months after right total hip replacement. Infection was diagnosed at microbiologic evaluation of a surgical specimen. Results of serial conventional radiography were true-positive, whereas those of PET (not shown) and bone scintigraphy were false-negative. A, Anteroposterior conventional radiograph obtained 6 months after total hip replacement is unremarkable. B, Anteroposterior conventional radiograph of the right hip obtained 9 months after A reveals caudal migration of the femoral shaft of 4 mm and osteolysis (arrows) at the bone-prosthesis interface (Gruen regions 1 and 7). C, Anterior bone scintigram obtained during the blood pool phase shows no pathologically increased uptake, and, D, anterior bone scintigram obtained during the late phase shows slightly increased uptake (arrows) around the trochanters and the tip of the prosthesis; this was interpreted as representing loosening. All images except A were obtained within 5 days of each other.

View larger version (158K): [in a new window]   Figure 3. Images obtained 16 years after right total hip replacement in 86-year-old woman with histopathologically proved foreign-body giant-cell granulomas. Results of microbiologic evaluation were negative for infection. Results of PET were false-positive: A, Corrected and, B, uncorrected coronal PET images show diffusely increased grade 4 FDG uptake (arrow) around the head, the trochanter, and the proximal shaft of the prosthesis. These results were interpreted as indicating infection. C, Anteroposterior conventional radiograph of right hip shows broad osteolysis (arrows) around the proximal femoral shaft; this was interpreted as indicating the presence of a granuloma.