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Review Article *Corresponding author Pelin Arıcan, Department of , Ankara Numune Education and Research Hospital, Talatpaşa Bulvarı 06300, Altındağ, Ankara, Turkey, Tel: 90-312- SPECT/CT for Assessment 5084877; Fax: 90-312-3126876; Email: of Extremities and Submitted: 15 June 2016 Accepted: 12 July 2016 Pelin Arıcan*, Bernatekin Okudan, and Nur Kodaloğlu Published: 13 July 2016 Department of Nuclear Medicine, Ankara Numune Education and Research Hospital, Copyright Turkey © 2016 Arıcan et al.

OPEN ACCESS Abstract

Planar bone is a radionuclide imaging used for the evaluation of Keywords many pathologies such as osteoarthritis, trauma, degeneration, and tumors • Bone in the joints of the upper and lower extremity. However, planar images cannot reach • satisfactory results especially in the wrist, foot and ankle with complex structures • Scintigraphy and small . Recently use of Single Photon Emission Computerize / • SPECT/CT Computerize Tomography (SPECT/CT) is increasingly widespread. SPECT/CT combines scintigraphic findings with morphological findings. It provides accurate anatomical localization of increased radiotracer uptake and evaluates morphological changes of this area. SPECT/CT increases diagnostic accuracy and specificity of planar bone scintigraphy. It improves patient management and treatment planning. Although bone SPECT/CT application is widely used in oncology patients, the number of studies about the role of assessment in the extremities and joints are limited. The aim of this review is to evaluate the contribution of bone SPECT/CT to the pathology of shoulder, elbow, hand-wrist, hip, knee, foot and ankle joint and to give examples from our cases.

ABBREVIATIONS CR: Conventional ; USG: Ultrasonography; CT: sensitivities and specificities. CR may not often reveal pathology Computed Tomography; MRI: Magnetic Resonance Imaging; in the early stages, and it may not determine pathological 3-PBS: Three-Phase Planar Bone Scintigraphy; WBS: Whole Body changes exactly. USG is an inexpensive and non-invasive Scan; SPECT/CT: Single-Photon Emission Computed Tomography/ method for the evaluation of soft tissues but it cannot evaluate Computed Tomography; Tc-99m MDP: Technetium-99m with the bony structures. CT is important in evaluating the bone and Labelled Phosphonates Compounds Methylenediphosphonate; surrounding soft tissues. MRI is important in evaluating the soft Tc-99m HDP: Technetium-99m with Labelled Phosphonates tissues, ligaments-tendons, and the bone marrow. However, both Compounds Hydroxyethylenediphosphonate; OM: Osteomyelitis techniques have disadvantages such as poor image quality due to metal implants and inability to detect small structural changes. INTRODUCTION Also they may not determine the metabolic activity [1,2]. The pathology of extremities and joints are common and Recently, even though MRI has new software and hardware to patients’ quality of life is negatively affected. In these cases, reduce noise distorting the image quality; noise problem cannot early diagnosis is very important to avoid permanent damage. be solved in the evaluation of prostheses after surgery especially Treatment of extremities and joint diseases depend on the on large joints, such as hip, and knees [1-4]. Bone scintigraphy is the most common use of radionuclide imaging technique for the evaluation of skeletal system [4]. incause. many The patients. clinical When examination clinical and and the laboratory findings ofexaminations laboratory are sufficient for the diagnosis of pathologies of extremities It is available widely, easily performed, and inexpensive. Technetium-99m with labelled phosphonates compounds are needed for diagnosis and treatment planning. Radiological (methylenediphosphonate, hydroxyethylenediphosphonate etc.) imagingdonot enough techniques find an such accurate as conventionaldiagnosis, the radiography imaging methods (CR), (Tc-99m MDP, Tc-99m HDP) are used for bone scintigraphy. ultrasonography (USG), computed tomography (CT), magnetic These compounds are collected in areas of increased bone resonance imaging (MRI), and radionuclide imaging techniques turnover. Soft tissues and bones are evaluated with three-phase such as bone scintigraphy, labelled leukocyte scintigraphy are planar bone scintigraphy (3-PBS). After a bolus injection of widely used for assessing extremity bones, and joints. These the Tc-99m with labelled phosphonates compounds, dynamic techniques have many advantages, disadvantages, different images are obtained. Blood pool images are acquired after perfusion images. Whole body and static images are Cite this article: Arıcan P, Okudan B, Kodaloğlu N (2016) Bone SPECT/CT for Assessment of Extremities and Joints. Ann Orthop Rheumatol 4(2): 1070. Arıcan et al. (2016) Email:

Central Bringing Excellence in Open Access SHOULDER AND ELBOW obtained 2-4 hours after injection. Soft tissue is evaluated with perfusion, and blood pool; bone is evaluated with whole body The shoulder and elbow pain are common findings due to scan (WBS) and static regional images. Although 3-PBS is the degenerative changes, tumoral or traumatic situations (Figure first option among radionuclide techniques for evaluation of 1-3). These pathologies cause impairment of joints functions. CR, the skeletal system, and has high sensitivity, its specificity may USG, and MRI are imaging methods are often used in shoulder be limited [1,2]. Planar scintigraphy must be combined with evaluation. Bone scintigraphy can be used when other imaging Single-Photon Emission Computed Tomography (SPECT) to methods are failed to achieve a diagnosis. Especially, it is useful increase specificity, however their diagnostic value is limited due for evaluation of the patients with shoulder pain in whom the to the poor accuracy in localizing increased uptake [1,2]. Hybrid findings of MRI suspected. It plays complementary role. The Single-Photon Emission Computed Tomography/Computed reports about use of bone SPECT/CT with Tc-99m MDP or HDP Tomography (SPECT/CT) system was developed. SPECT/CT can for the shoulder is limited. Recently, the number of patients improve the prognostic value of planar radionuclide techniques who operated for shoulder prosthesis increased. Although since it evaluates morphologic and functional information there are limited studies on the use of bone SPECT/CT for the together [1,2]. Both scintigraphic and tomographic imaging patients who suspected post-operative complication, the results can be performed in the same session without changing the are promising. Hirschman showed that SPECT/CT is useful for patient’s position with SPECT/CT. Fused images are obtained by determining the loosening humeral, and glenoidal components overlapping both images. By this manner, SPECT/CT shows actual in the patients with shoulder prosthesis and for the evaluation anatomical localization of radiotracer uptake on planar scan, of the acromioclavicular joint osteoarthritis and also, the pain and differentiation of bone-soft tissue can be made. SPECT/CT associated with subacromial impingement [10]. increases diagnostic accuracy of scintigraphy with the evaluation It is difficult to distinct the from the increased of bone and soft tissue morphology with CT component. To activity due to degenerative changes in the shoulder in the sum up, SPECT component of SPECT/CT increases sensitivity, cancer patients with the WBS. SPECT/CT can reach the correct CT component increases specificity [4,5]. The use of SPECT/CT diagnosis by evaluating the bone morphology and making with bone scintigraphy and tumor imaging agents has become accurate anatomic localization for these patients. Although widespread in the evaluation of cancer patients [6.7]. But SPECT/ osteoid osteoma is rarely seen in the shoulder, it can occur in CT has not been used frequently in orthopedic diseases and the coracoid process, the glenoid fossa, the body of scapula and there is not an adequate evidence for evaluation of orthopedic acromion. SPECT/CT is very useful for localization and treatment pathologies [8,9]. planningHAND AND of osteoid WRIST osteoma [11]. In this review, we discussed the role of bone SPECT/CT for evaluation of the shoulder, elbow, wrist, hand, hip, knee, ankle and foot, and its clinical applications with examples from our The diagnosis of hand, and wrist problems is difficult. The cases. most common finding is pain. The exact localization of the pain

Figure 1

Tc-99m MDP bone scintigraphy of 60 years old woman with right shoulder pain for two months. (A) Minimal focal radiotracer uptake is seen on the right acromioclavicular joint in anterior late static image (arrow), but (B) posterior late static image does not show increased osteoblastic activity in same localization. (C) In the axial CT and SPECT/CT images the medullar sclerotic rim is seen on the caput humeri associated with focal increased uptake (arrows). These fusion images are suggested benign bone pathology. (D) MRI revealed a 10 mm. hyperintense lesion on the caput humeri as suspectedenchondroma (arrow). The patient is followed up. In this patient, bone SPECT/CT confirms the accurate diagnosis of lesion which is found by MRI. Also, WBS provides to evaluation of possible other lesions in whole body bones. Ann Orthop Rheumatol 4(1): 1070 (2016) 2/10 Arıcan et al. (2016) Email:

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Figure 2

Tc-99m MDP bone scintigraphy of 63 years old man with left shoulder pain for four months. MRI reveals a subcortical lesion on the spine of left scapula. WBS is performed to determinate the metabolic activity of this lesion.(A) Pathologic radiotracer uptake is not seen in anterior late static image, but (B) posterior late static image shows minimal focal osteoblastic activity on the left acromion (arrow). (C) Axial CT and SPECT/CT images. The subcortical radiolucent area is seen on the acromion of the left scapula associated with focal increased uptake (arrows). These fusion images are suggested subcortical cyst. Bone SPECT/CT supports the findings of MRI and confirms as benign lesion.

Figure 3

Tc-99m MDP 3-phase bone scintigraphy of 26 years old woman with pain and swelling in the left elbow. (A) Blood pool image shows central oligemic area around the hyperaemia (arrow). (B) Late static image shows slightly increased osteoblastic activity in left elbow (arrow). (C) Coronal and (D) axial CT, and SPECT/CT fusion images describe soft tissue mass corresponding to increased radiotracer uptake on the planar bone scan. No pathologic uptake and morphologic changes in the bone structure (arrows). Malign mesenchymal tumor is confirmed by pathologic examination.WBS SPECT/CT shows no bone invasion and metastasis in other bone structures. Fusion images determine metabolic active area into the mass which is found by MRI and guide the biopsy. may not be done clinically as a result of many joints, intrinsic and The most important advantage of MRI is to detect the changes of extrinsic ligaments, tendons and small bones located in the hand the joints, soft tissue around the joint, and bone marrow oedema and wrist. Radiological imaging methods are usually needed for in the early stages. However these imaging techniques’ success diagnoses. Conventional radiography is the first imaging choice. is limited in diagnosis of metabolic diseases. Bone scintigraphy If radiography is not beneficial, CT and MRI are suggested. allows evaluating the hand and wrist metabolic disease. PBS has Morphological changes in the carpal bones can be shown with CT. a difficulty in localization of increased pathologic radiotracer Ann Orthop Rheumatol 4(1): 1070 (2016) 3/10 Arıcan et al. (2016) Email:

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uptake due to complex anatomy of wrist. SPECT/CT is more to display ligament and structure in the carpal region. valuable for the evaluation of the patients with pain in the wrist This new imaging modality can be beneficial for the patients and hand than PBS. Florion reported that SPECT/CT detected with ulnar impaction syndrome. SPECT/CT arthrography allows 20% more lesions compared with CR and PBS [12]. Huel have the visualization of scapholunate and lunatriquetral ligaments demonstrated that providing high interobserver agreement [17]. Consequently, SPECT/CT should be used as complementary when bone scintigraphy interpreted with the SPECT/CT [13].In HIPmethod in hand and wrist disorders when MRI is equivocal. particular, SPECT/CT plays an important role in the detection of occult fractures which cannot be shown with other imaging methods, in the pursuit of post-traumatic bone healing, in Much hip pathology may cause pain and disrupt the function making the precise localization of the increased focal radiotracer of the joint. The osteoarthritis is an important pathology of in PBS (Figure 4). Allinment reported that SPECT/CT is better to the hip. is widely treatment choice preferred for distinguish occult fracture in the wrist compared to CT [14]. osteoarthritis of the hip. The clinical results of the total hip Ulno-carpal region is frequently affected by the trauma and arthroplasty are satisfactory in most of the cases, but several degenerative diseases. SPECT/CT allows to distinguish ulno- complications such as , aseptic and septic loosening, carpal impingement, carpal tunnel syndrome and Kienbock’s intraoperative fracture and heterotopic ossification may be seen. disease [15,16]. Early diagnosis of Kienbock’s disease is important Loosening and infection are the most common complications to prevent permanent damage formation. When the result of [1-3]. Loosening in acetabular and femoral component occurs radiography is negative and MRI is suspicious, bone SPECT/CT in approximately 10% of patients, and infection in 1-2% of plays an important role in early diagnosis [16]. Metacarpal joint the patients [19]. CR is the first imaging modality used in the disorders, occult fractures, and lesions such as ganglion cyst of the evaluation of complications. However this method is not both carpal bones give similar results in the PBS. However, accurate sensitive and specific. CT and MRI are useful in the evaluation of the position of the prosthesis, bone structures and surrounding diagnosis is very important due to differenceand in their treatments. Also, SPECT/CT has a great benefit in evaluation of inflammatory soft tissues, but noise is caused by metal limits their use. diseases such as rheumatoid arthritis psoriatic arthritis. 3- PBS is the most commonly used method for the evaluation of The most important disadvantage of MRI is metal implants, hip prosthesis. The increased periprostetic activity has continued after the hand and wrist surgery. Metal artefacts cause poor for at least one year in bone scintigraphy due to remodelling image quality. Bone SPECT/CT is sufficient for the evaluation of bone after operation. This period may be longer in some of hyperdens bone structure despite of metal artefacts and it is patients with cementless prostheses up to 2 to 3 years [1,18,20]. useful for detection of post-surgical changes and complications. To distinguish loosening from infection and early diagnosis are very important, because treatment options are different. It The combination of CT arthrography and SPECT/CT called cannot always be easy to distinguish loosening from infection SPECT/CT arthrography is an effective method that can be used with PBS. SPECT/CT has an important role in evaluation of hip

Figure 4

A 58 year-old woman with suspected infection after distal radius fracture 2 years ago. She has wrist pain, swelling and erythema. Three phase bone scan is performed to confirm the infection. (A) Blood pool phase shows hyperemia in the wrist and (B) late static image shows focal radiotracer uptake in the distal radius. (C) Axial CT (D) fusion SPECT/CT images reveal intense increased activity in the distal radius and corresponding to the lower of fixator. Acute infection of around the fixator is confirmed by bone SPECT/CT. Antibiotic therapy is started. In this patient, MRI is not useful because of metal artifact. Ann Orthop Rheumatol 4(1): 1070 (2016) 4/10 Arıcan et al. (2016) Email:

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prosthetic complications. However, the number of publications 94.1%) [23]. Acetabular region is exposed to the mechanical on this subject is limited. Strobel reported that SPECT/CT with trauma due to rubbing of the caput femoris. Increased radiotracer PBS is promising for the evaluation of arthroplasties [21]. Tam uptake may be seen in the acetabular region due to mechanical recommended that SPECT/CT should be performed for the trauma. Differentiating loosening of acetabular component due correct interpretation of the PBS in hip prosthesis complications to mechanical trauma is difficult with PBS and SPECT. SPECT/CT [22]. In our study, we found sensitivity as 77% for PBS, as 93.7 % can distinguish mechanical trauma from loosening owing to its for SPECT/CT in the evaluation of hip and knee prosthesis [23]. ability to demonstrate anatomical localization. We revealed that SPECT/CT increased the diagnostic accuracy of MRI is the first imaging modality of choice the diagnosis of the prosthesis complications, by making the actual anatomical . When it is contraindicated in patients who localization of the increased activity in bone scintigraphy and have fracture and metallic implant-fixation material in the identifying morphological changes in the bone structure and femoral head or it is inadequate, SPECT/CT has an important surrounding soft tissue (Figure 5). Bone and soft tissue changes contribution in these cases (Figure 6). SPECT/CT increases obtained by CT component, such as prosthesis malposition, the diagnostic accuracy of PBS and SPECT. Agarwal was found osteolysis, periprostetic radiolucency, fractures, calcification, diagnostic accuracy (95%), sensitivity (98%), and specificity abscesses, oedema, fistula, accumulation of fluid in the joint (87%) of SPECT/CT [26]. Stress fractures and osteoid osteoma contributed significantly to distinguish the loosening from the are other pathologies of the hip, SPECT/CT is reported to be infection. According to meta-analyses, sensitivity and specificity KNEEbeneficial for them [27]. of bone scintigraphy for aseptic loosening of the femoral component are 72 %, 85% and for the acetabular component 67%, 83%, respectively in hip prosthesis [24,25]. According to the Knee pathologies are commonly seen and the most common results of our study, SPECT/CT is more useful to detect loosening symptom is pain. CR is the first preferred method in the of acetabular component when it is compared to femoral evaluation of knee pathology as well as in the hip. MRI is generally component (sensitivity for acetabular component; 57.8% versus required for evaluation of meniscuses, ligaments, cartilage and 89.4%; and sensitivity for femoral component; 93.1% versus

Figure 5

Aseptic loosening of femoral and acetabular components in an 83-year-oldman who has hip prosthesis 2 years ago. (A) Blood pool image is normal. There is focal activity on acetabular component (arrow), and a minimal activity on femoral component. (B,C) Axial and sagittal SPECT/ CT images show diffuse increased radiotracer uptake in periacetabular (arrow) and femoral regions. Loosening is differentiated from mechanical trauma in acetabular region with SPECT/CT. Aseptic loosening is confirmed at surgery. Ann Orthop Rheumatol 4(1): 1070 (2016) 5/10 Arıcan et al. (2016) Email:

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Figure 6

39 years old men who has bilateral hip pain for three months and suspected avascular necrosis with findings of MRI. Three phase bone scan is performed to determine the stage of avascular necrosis. (A) There is no pathologic uptake in blood pool images. (B) Late anterior static image shows mild (thin arrow) and slight (thick arrow) focal increased radiotracer uptake in the bilateral hip. (C) Axial and (D) coronal SPECT/CT images show intense focal increased radiotracer uptake in both femoral head (arrows). These findings are interpreted as intermediate phase of avascular necrosis. The patient will be operated. Bone SPECT/CT completes MRI findings and manages the patient therapy. bone structures. Radionuclide methods play a complementary decision of unicompartmental or total arthroplasty, and patellar role in cases which MRI cannot be done and/or equivocal [1]. resurfacing addition to the procedure. Bone scintigraphy and SPECT/CT are used in the evaluation of The activity of osteoarthritis is very important for planning osteoarthritis, osteochondral lesions, osteonecrosis, painful knee treatment. There is no relation between the activity of prosthesis and bone tumors (Figure 7). osteoarthritis and morphological changes. Therefore, radiologic As for the hip, 3- PBS is the first choice radionuclide technique imaging techniques are not useful for the evaluation of the for the evaluation of painful knee prosthesis. After the knee osteoarthritis activity. But, it can be interpreted the activity prosthesis surgery, periprostetic physiological activity generally of osteoarthritis looking at the intensity of increased activity continues up to 1 year. Sensitivity and specificity of 3-PBS are detected by bone scintigraphy. In the study of Hirschmann between 88%-92%, 76-100% respectively for the evaluation of showed more accurately activity and prevalence of osteoarthritis by adding SPECT/CT to bone scintigraphy [29]. loosening and infection [28]. Recently, the use of the SPECT/CT arthrography for knee has Adding SPECT/CT to PBS provides information about the increased the value of SPECT/CT. This technique is particularly position of the prosthesis, morphological changes in the bone useful in scanning after intraarticular radionuclide treatment structure and surrounding soft tissue as in hip. [31]. Chew used the SPECT/CT arthrography to evaluate the In studies of Hirschmann SPECT/CT contributes to the loosening of prostheses in hip and knee. They found that SPECT/ determination of the diagnosis of prosthetic malposition, CT arthrography is superior to the planar images in the loosening patellofemoral pathology and loosening in 83% patients of the acetabular component. Although this method was superior with painful knee prostheses. SPECT/CT allows high intra- in detection of loosening of the tibial component, statistically interobserver agreement [29]. Al Nabhani determined that significant difference was not found [32]. SPECT/CT confirmed the diagnosis in 21 of 24 patients who SPECT/CT provides important information on diagnostic underwent knee prosthesis revision surgery, and distinguished accuracy, and extension of benign and malignant tumors such as aseptic loosening from infection and patellofemoral arthritis osteoid osteoma, , osteoblastoma, giant cell tumor [30]. Also evaluating three compartments of the knee joint and of the knee. It plays an important role in the (femoropatellar, medialfemorotibial, lateralfemorotibial) detection of multifocal localization and distant bone metastases with bone SPECT/CT provides important information for the when combined with whole-body scan [1,4]. Ann Orthop Rheumatol 4(1): 1070 (2016) 6/10 Arıcan et al. (2016) Email:

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Figure 7

Tc-99m MDP bone scintigraphy of 37 year-old man who has pain and slight swelling in the right knee. Hewas operated due to synovitis six years ago. (A) Blood pool image is normal. (B) There are focal radiotracer uptake in the lateral of right knee and medial of left knee in late static images (arrow). (C) Axial CT and (D) coronal SPECT/CT images show lytic-sclerotic area in the lateral condyle of left knee with increased focal radiotracer uptake. The patient is interpreted to have osteonecrosis of left knee according to MRI findings (arrows). Bone SPECT/CT confirms the diagnosis. FOOT AND ANKLE SPECT/CT can be used for follow-up of the changes​ after the made for pseudoartrosis, subtalar The diagnosis of the foot and ankle diseases is difficult joint osteoarthritis, and the healing of the calcaneal fracture clinically, due to small bone structures and complex multiple (Figure 8). Pagenstent reported that it is very important to joints. The most common symptom is pain. Primary diagnostic make accurate localization of osteoarthritis in the complex methods in foot and ankle diseases are clinical examination and joints regions such as foot and ankle for planning the effective CR. USG, CT or MRI can be performed for differential diagnosis. treatment and the selection of patients needed surgery. MRI and USG have advantages in soft tissue but low specificity for [36]. bone pathologies [33]. CT can be illustrating bone pathologies, but it cannot give information about the activity of the pathology. SPECT/CT is the ideal imaging model for the detection of 3- PBS is frequently used to evaluate the activity of foot and ankle osteoid osteoma which is rarely seen in the foot bones. The nidus bone pathologies. Adding SPECT/CT to 3-PBS provides important and increased activity on the lesion can be shown at the sometime supporting the diagnosis of osteoid osteoma. MRI may difficult to clinical information for evaluating in particular diabetic foot infection, inflammatory and traumatic diseases, degenerative distinguish the nidus from the small tarsal bones due to intense diseases, accessory sesamoid bone, osteochondrosisdissecans bone marrow edema [37]. and osteoarthritis. It plays an important role in the selection SPECT/CT arthrography provides evaluation of the of treatment modalities such as corticosteroid injection or joint cartilage, synovial changes and joint structures just as arthrodesis [1]. SPECT/CT changed the treatment plan in 78% of wrist and knee. SPECT/CT arthrography provides important 39 patients with foot pain according to a study which was done information about bone metabolism, joint cartilage and the by Singh. They reported the accuracy, sensitivity, specificity, stability of osteochondral lesions after treatment, especially for positive and negative predictive values ​ of bone SPECT/CT osteoarthritis of ankle and osteochondral lesions of talus. as 94%, 95%, 83%, 98%, and 71% respectively [33]. SPECT/ Achilles tendinitis, and stress fractures CT is useful for the pathologies of foot and ankle to be treated are particularly common injuries of long distance runners. by surgery. Claassen showed high accuracy for the decision of Clinical examination, USG, and MRI are successful methods for surgical treatment of foot and ankle with SPECT/CT especially diagnosis. SPECT/CT has also been shown to be successful in in Chopart and Lisyranc joint [34]. Also Chicklor reported that the differential diagnosis of these pathologies. Stress fractures bone SPECT/CT was beneficial for the most common causes of are not rarely seen pathology of foot and most frequently seen chronic foot and ankle pain as impingement syndrome and soft in 1-2.metatarsal bones. Stress fractures of the metatarsal and tissue pathologies [35]. Ann Orthop Rheumatol 4(1): 1070 (2016) 7/10 Arıcan et al. (2016) Email:

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Figure 8

46 year-old woman patient who hasright ankle pain for 6 months is performed bone scintigraphy. She has history of no trauma to the right ankle and foot. X-Ray is normal. (A) Anterior and (B) lateral planar late bone images show focal increased osteoblastic activity in the right ankle (arrows). (C) Axial and (D) sagittal SPECT/CT images show fracture of the anterior of the right talus with increased focal radiotracer uptake at the fracture site (arrows). The patient is confirmed as fracture with MRI. Bone SPECT/CT shows the viability fracture line with increased metabolic activity. sesamoid bones are usually determined by the PBS. However, reduces false-positive or suspicious results in the patients with diseasesthe exact anatomic and localization of activity cannot be done. It is suspected OM [38]. Diabetes mellitus and peripheral arterial very important to distinguish stress fractures from degenerative disease increases the probability of OM especially in foot. 3-PBS osteochondrosis dissecans, because of their is a beneficial method for accurate diagnosis and treatment in treatments are different. Stress fractures appear as increased the patients with diabetic foot infection. The addition of SPECT/ uptake in the fracture line or hyperdense areas on SPECT/CT CT is very useful in the differential diagnosis of the OM and soft images. In addition, separation of new and old fractures can be tissue infection and actual anatomic localization of OM in small done with SPECT/CT. bone structures. Heiber evaluated the diabetic foot and OM with dual isotope Tc-99m MDP bone scan and Indium-111 (In- Plantar fascia extends between tuberositas calcanei and the 111) labelled leukocytes SPECT/CT imaging [39]. They found heads of the metatarsal bones and supports the arch of the foot. that dual isotope SPECT/CT provides significant improvement Plantar fasciitis is the inflammatory changes and ruptures that in the differentiation of the OM from soft tissue infection occurs due to micro trauma or overuse of the plantar fascia. It is compared with planar studies. To differentiate acute OM from often seen as a focal increase in activity in tuberositas calcanei chronic active OM accuratelyis difficult with 3- PBS since their in bone scintigraphy. This finding also occurs in stress fractures scintigraphic findings are similar, but it is very important since in calcaneus. SPECT/CT plays an important role in distinguishing their treatment options. Morphological findings are obtained by the plantar fasciitis from [2,37]. SPECT/CT provides an important contribution to the differential SPECT/CT can easily make the differential diagnosis of diagnosis of chronic infection and the acute infection. SPECT/CT pathologies as ostrigonum or accessory navicular bone that demonstrates morphological changes of soft tissue (soft tissue cause pain. edema, abscess, fistula tract, etc.) and bone (cortical destruction, sequestration, involucra, etc.) associated with increased tracer Tarsal coalition is a deformity caused by bridging of fibrous, THEuptake LIMITATIONS [3,38]. OF SPECT/CT cartilage or bone tissue between two or more tarsal bones. Sometimes calcaneonavicular and talocalcaneal coalition cannot be noticed with CT or even with MRI [37]. Combining metabolic and morphological data with SPECT/CT and comparing with the The limitations of SPECT/CT are the high radiation dose and other side is very useful in these patients. cost. Patients with suspected pathology in the extremities often require several radiologic imaging modalities as X-Ray, diagnostic There are several studies about reporting the role of SPECT/ CT before the correct diagnosis can be. Radiation exposure dose CT for diagnosis of osteomyelitis (OM) and diabetic foot. Horger of radiologic methods is much more than the SPECT/CT [29,40]. investigated the value of bone SPECT/CT in patients with SPECT/CT studies increase radiation exposure compared to suspected bone infections. They found that specificity of SPECT/ planar bone scan and SPECT. SPECT/low dose CT is associated CT was significantly higher (50% to 86%), while sensitivity of with low radiation dose such as 1-4 mSv with a single bed PBS+SPECT and SPECT/CT was similar (78%). They reported position (FOV=40 cm). SPECT/low dose CT is usually sufficient that SPECT/CT improves the diagnostic accuracy of 3-PBS and for the diagnosis of pathology and for anatomic localization, but Ann Orthop Rheumatol 4(1): 1070 (2016) 8/10 Arıcan et al. (2016) Email:

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sometimes there is need for more spatial resolution, and high algoritm of nononcologic patients referred for bone scintigraphy. J Nucl Med. 2007; 48: 319-324. image quality for evaluation of morphologic changes. Especially, the evaluation of small bone structures in the foot, and hand are 9. Linke R, Kuwert T, Uder M, Forst R, Wuest W. Skleletal. SPECT/CT of difficult with low dose CT. The accuracy of SPECT/CT images might the peripheral extremities. AJR Am J Roentgenol. 2010; 194: 329-335. be increased by replacing low dose CT with spiral multi-slice CT. 10. Hirschmann MT, Schmid R, Dhawan R, Skarvan J, Rasch H, Friederich Nowadays, spiral multi-slice SPECT/CT is already commercially NF, et al. Combined single photon emission computerized tomography available. But high radiation dose of SPECT/multi slice CT such and conventional computerized tomography: clinical value for the as 6-14 mSv shouldn’t be ignored [40]. We use SPECT/low dose shoulder surgeons? Int J Should Surg. 2011; 5: 72-76. CT (Millennium Hawkeye4,GE Medical Systems,Milwaukee, WI) 11. Degreef I, Verduyckt J, Debeer P, De Smet L. An unusual cause of in our department. The images presented in this review are taken shoulder pain: osteoid osteoma of the acromion- a case report. J with low dose CT. Shoulder Elbow Surg. 2005; 14: 643-644. Cost effectiveness of SPECT/CT when compared to other 12. Schleich FS, Schürch M, Huellner MW, Hug U, von Wartburg U, Strobel imaging modalities is not definitely put forwardyet. However, K, et.al. Diagnostic and therapeutic impact of SPECT/CT in patients with unspecific pain of the hand and wrist. EJNMMI Res. 2012; 2: 53- SPECT/CT can decrease time for initiating treatment, anxiety of 61. patients, prevent unnecessary treatment and hospital visits, and additional laboratory/ radiological investigations. Considering 13. Huellner W, Bürkert A, Strobel K, del Sol PérezLago MS, Werner L, Hug those results, cost of SPECT/CT may be ignored. Therefore, U, et al. Imaging non-specific wrist pain: Interobserver agreement and diagnostic accuracy of SPECT/CT, MRI, CT, bone scan and plain SPECT/CT should be preferred particularly in patients with radiographs. PLos One. 2013; 8: e85359. confusingCONCLUSION bone scan findings. 14. Allainmant L, Aubault M, Noel V, Baulieu F, Laulan J, Eder V. Use of hybrid SPECT/CT for diagnosis for radiographic occult fractures of the wrist. Clin Nucl Med. 2013; 38: 246-251. Three phase bone scan is the first choice technique among the radionuclide procedures for the evaluation of patients 15. Ito S, Yamamoto Y, Tanii T, Aga F, Nishiyama Y. SPECT/CT imaging in ulnacarpal impaction syndrome. Clin Nucl Med. 2013; 38: 841-842. with suspected pathology on extremities and joints. Planar images combined with SPECT/CT are useful tool in diagnosis 16. Arora S, Singh Dhull V, Karunanithi S, Kumar Parida G, Sharma of these pathologies. SPECT/CT can change the diagnosis and A, Shamim SA. (99m)Tc-MDP SPECT/CT as the one-stop imaging management option of the patients due to correct anatomical modality for the diagnosis of early setting of Kienbock’s disease. Rev Esp Med Nucl Imagen Mol. 2015; 34: 185-187. localization of radioactive uptake, and evaluation of bone-soft tissue morphological changes. SPECT/CT plays a supplemental 17. Kruger T, Hug U, Hullner MW, Schleich F, Veit-Haibach P, von Wartburg role in suspected cases which exact diagnosis cannot be done U, et al. SPECT/CT arthrography of the wrist in ulnacarpal impaction with CR, CT and MRI. Fusion images increase the specificity of syndrome. Eur J Nucl med Mol Imaging. 2011; 38: 792. planar bone scan in the compact joint and small bone structures 18. Palestro CJ. Nuclear medicine and failed replacement: Past, present, as wrist, hand, foot, and ankle. SPECT/CT seems to be an and future. World J Radiol. 2014; 28: 446-458. encouragingREFERENCES method for diagnosis and evaluation of extremities. 19. Berquist TH. Imaging of joint replasman procedures. Radiol Clin Nourth Am. 2006; 44: 419-437.

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Cite this article Arıcan P, Okudan B, Kodaloğlu N (2016) Bone SPECT/CT for Assessment of Extremities and Joints. Ann Orthop Rheumatol 4(2): 1070.

Ann Orthop Rheumatol 4(1): 1070 (2016) 10/10