Hybrid Imaging of Complicated Osteomyelitis in the Central and Peripheral Skeleton

Dear Colleagues,

Nuclear medicine techniques play an important role in non-invasive imaging of several types of posttraumatic and postsurgical osteomyelitis in the peripheral and central skeleton, using both planar, single-photon emission tomography (SPECT) and positron emission tomography (PET) radiopharmaceuticals. Furthermore, in contrast to structural imaging modalities, NM procedures have the advantages of being less susceptible to attenuation or metal artifacts due to implants. For this purpose,

there are a myriad of scintigraphic tests from which to choose. However, it is well known that these conventional imaging modalities do not perform well in the distinction between soft tissue and deep bone infection, due to the lack of anatomical information. These difficulties have been overcome, to a great extent, with the introduction of in-line SPECT/CT and PET/CT/MRI systems, which have revolutionized the field of diagnostic medical imaging.

Hybrid imaging is especially useful in sites of suspected COM with underlying structural bone alterations and metallic implants, as frequently encountered in posttraumatic and postsurgical conditions. The first clinical studies using these integrated hybrid machines in the field of osteomyelitis imaging are highly promising, especially in postoperative spinal infections, prosthetic joint infections, fracture-related infections, and diabetic foot infections.

In summary, FDG-PET combined with CT seems to be the most accurate single modality for imaging COM in the central as well as peripheral skeleton, compared to traditional radionuclide imaging tests. Firstly, PET-CT offers the advantage of locating abnormalities more precisely, and is capable of monitoring treatment response. Secondly, it is an all-in-one technique completed within 2 hours, and the patient dose is lower. Thirdly, it is a robust technique with high interobserver agreement and NPV, excluding COM, with high certainty. Unfortunately, there are still false positives, especially in the early postsurgical period and also in the presence of spinal implants or tibial delayed union, resulting in a lower specificity and PPV. Therefore, the holy grail is still imaging bacteria with specific radiopharmaceuticals, hopefully as a realistic option or an illusion!

Finally, in the future, the complementary use of hybrid SPECT and especially radiolabeled compounds for PET-based infection imaging combined with CT or MRI may overcome some of the challenges faced in the assessment of COM.

Dr. Filip F.A.Y. Gemmel
Dr. Charito Love
Guest Editors

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• chronic osteomyelitis
• violated bone
• PET
• SPECT
• hybrid imaging