Central Annals of Orthopedics & Rheumatology Bringing Excellence in Open Access Review Article *Corresponding author Pelin Arıcan, Department of Nuclear Medicine, Ankara Numune Education and Research Hospital, Talatpaşa Bulvarı 06300, Altındağ, Ankara, Turkey, Tel: 90-312- Bone SPECT/CT for Assessment 5084877; Fax: 90-312-3126876; Email: of Extremities and Joints 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 scintigraphy is a radionuclide imaging used for the evaluation of Keywords many pathologies such as osteoarthritis, trauma, degeneration, infections and tumors • Bone in the joints of the upper and lower extremity. However, planar images cannot reach • Joint satisfactory results especially in the wrist, foot and ankle with complex structures • Scintigraphy and small bones. Recently use of Single Photon Emission Computerize Tomography/ • 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 Radiography; 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 Whenexamination 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 conventional diagnosis, 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 perfusion 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 metastasis 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: Central Bringing Excellence in Open Access