Accuracy comparison of various quantitative [99mTc]Tc-DPD SPECT/CT reconstruction techniques in patients with symptomatic hip and knee joint prostheses

Background There is a need for better diagnostic tools that identify loose total hip and knee arthroplasties. Here, we present the accuracy of different 99mTc-dicarboxypropandiphosphate ([99mTc]Tc-DPD) SPECT/CT quantification tools for the detection of loose prostheses in patients with painful hip and knee arthroplasties. Methods Quantitative reconstruction of mineral phase SPECT data was performed using Siemens xSPECT-Quant and xSPECT-Bone, with and without metal artefact reduction (iMAR) of CT-data. Quantitative data (SUVmax values) were compared to intraoperative diagnosis or clinical outcome after at least 1 year as standard of comparison. Cut-off values and accuracies were calculated using receiver operator characteristics. Accuracy of uptake quantification was compared to the accuracy of visual SPECT/CT readings, blinded for the quantitative data and clinical outcome. Results In this prospective study, 30 consecutive patients with 33 symptomatic hip and knee prostheses underwent [99mTc]Tc-DPD SPECT/CT. Ten arthroplasties were diagnosed loose and 23 stable. Mean-SUVmax was significantly higher around loose prostheses compared to stable prostheses, regardless of the quantification method (P = 0.0025–0.0001). Quantification with xSPECT-Bone-iMAR showed the highest accuracy (93.9% [95% CI 79.6–100%]) which was significantly higher compared to xSPECT-Quant-iMAR (81.8% [67.5–96.1%], P = 0.04) and xSPECT-Quant without iMAR (77.4% [62.4–92.4%], P = 0.02). Accuracies of clinical reading were non-significantly lower compared to quantitative measures (84.8% [70.6–99.1%] (senior) and 81.5% [67.5–96.1%] (trainee)). Conclusion Quantification with [99mTc]Tc-DPD xSPECT-Bone-iMAR discriminates best between loose and stable prostheses of all evaluated methods. The overall high accuracy of different quantitative measures underlines the potential of [99mTc]Tc-DPD-quantification as a biomarker and demands further prospective evaluation in a larger number of prosthesis.

Femoroacetabular Impingement of the Hip Joint – Literature Review

Introduction: In patients with painful hip joint, femoroacetabular impingement is a relatively frequently diagnosed condition. Study aim: The aim of the study was to present the anatomy, biomechanics and pathomechanism of femoroacetabular impingement, surgical diagnostics and treatment, as well as physiotherapeutic procedures, and to provide answers to the following questions: 1. What are the causes of femoroacetabular impingement development and what is its most common form? 2. What are the clinical and imaging diagnosis of femoroacetabular impingement based on? 3. What are the goals of physiotherapeutic treatment in the treatment of patients with postoperative femoroacetabular impingement? Material and method: Current professional literature was analysed based on a review of Internet databases, including Pubmed and Google Scholar. Results: From the abovementioned Internet databases, 30 items from the current profession-al literature on the analysed variables were identified. Conclusions: The reasons for the development of femoroacetabular impingement are com-plex, including developmental disorders of the hip joint or its chronic overload. Its most common form is mixed type. The basic imaging test used is anterior-posterior X-ray, while clinical assessment is based on anterior-posterior impingement test. Physiotherapy should be individually tailored and focused on improving range of motion and muscle strength of the hip joint.

Painful Total Hip Arthroplasty: A Systematic Review and Proposal for an Algorithmic Management Approach

Background: The etiological diagnosis of painful primary total hip arthroplasty and its management is a complex clinical challenge for pain physicians. Extrinsic sources of pain in the hip joint might be efficiently treated by clinical pain units, although the topic remains controversial. Objectives: To conduct a literature review and suggest an evidence-based algorithmic approach to managing painful hip arthroplasty. Study Design: Systematic literature review with qualitative data synthesis. Methods: We conducted an online search of Medline/Pubmed, Embase, Clinical Trials, and Cochrane database using the Medical Subject Heading (MeSH) and free terms on all biomedical literature published up to August 2019. Articles that described either the etiologies and management of painful primary total hip arthroplasty or the imaging techniques to specifically assess any of its causes were included. We collected the demographic data (gender, age, body mass index), main etiologies, diagnostic tests, and specific treatments applied in each study. Based on the reviewed evidence, we propose an algorithmic approach, with a special emphasis on etiologies that should be referred to pain clinics. Results: Twenty-four studies were included for the synthesis, 16 of which were observational studies and 8 of which were non-systematic literature reviews that described a wide range of etiologies of painful primary total hip arthroplasty. The results showed that 2/3 of the causes of pain were intrinsic and need to be managed by orthopedic surgeons. One third of the etiologies were extrinsic and should be referred to pain clinics once intrinsic causes have been ruled out. Among extrinsic sources of pain, the most frequent was myofascial etiology. Limitations: A publication bias might have been present due to the inclusion of studies published only in English, Spanish, and German. The included studies also had heterogeneous methodologies. Conclusions: The current review suggests that painful hip arthroplasty is not a rare condition in clinical practice. We systematically reviewed etiologies and various treatments published in the literature and we suggest an algorithmic approach to management based on the available evidence. This approach incorporates the evidence regarding our knowledge of the etiologies, diagnosis, and management of chronic pain after total hip arthroplasty. Systematic review registration: The protocol was registered in PROSPERO the international prospective register of systematic reviews, ID CRD42020185663. Key words: Chronic pain, review, pain management, arthroplasty, hip replacement

Razi and his Concepts on Bone and Joint Disorders

This brief review presents Razi’s concepts of bone and joint disorders. Razi differentiated between ligaments, tendons, and nerves and recognized the role of the brain, spinal cord, and peripheral nervous system in the perception of senses and voluntary movements. He described paralysis and loss of sensation following brain, spinal cord, and peripheral nervous system injuries. Razi presented an early concept of compartment syndrome. Razi’s approach to fracture management is very similar to the current concept of functional bracing for some fractures. Razi mentioned suturing the wounds and ligation of bleeding large vessels. He cautioned about phlebotomy in the antecubital fossa as it may become complicated by the adjacent arterial and nerve injuries. Razi treated osteomyelitis by removing the infected and necrotic bone by sawing, cutting, and rasping. He also documented arthralgia, painful hip, and sciatic pain and made a sharp distinction between arthralgia and gout. He indicated the gout origin as the production of a waste substance that the body fails to expel. Razi’s basic concepts on the bone and joint disorders established a foundation for modern orthopedic science.

Systematic Review on Reproducibility of Nuclear Imaging in the Assessment of Painful Hip and Knee Replacements

Nuclear imaging is used in the evaluation of painful arthroplasties for diagnosing loosening or periprosthetic joint infection (PJI). The purpose of this systematic review is to depict the reproducibility of the various nuclear imaging modalities used in the assessment of painful hip and knee arthroplasties. A systematic review of the literature was conducted with a comprehensive search of MEDLINE to identify clinical studies investigating the intra-and inter-observer agreement of nuclear imaging modalities in diagnosing PJI and mechanical loosening. A total of 3.000 studies, published between 2004 and 2020, were reviewed and 16 studies met the inclusion criteria. Quality assessment identified concerns with regard to the internal validity in approximately 40% of the included studies. A meta-analysis could not be performed because of insufficient available clinical data. The intra-observer agreement was poorly investigated. The included studies reported an inter-observer agreement of “slight” to “excellent” for bone scintigraphy, “moderate” to “substantial” for leukocyte scintigraphy, “substantial” to “almost perfect” for combined leukocyte and bone marrow scintigraphy, and “fair” to “substantial” for anti-granulocyte scintigraphy. Hybrid imaging with SPECT/CT and FDG-PET/CT demonstrated “substantial” and “almost perfect” inter-observer agreement for symptomatic hip prostheses, respectively. The reproducibility of nuclear imaging is underreported in clinical studies investigating painful knee and hip arthroplasties. Moreover, the included studies demonstrated methodological concerns with a high risk of bias. The available evidence demonstrated a wide range of inter-observer agreement using scintigraphy. Hybrid imaging with SPECT/CT and FDG-PET/CT may improve the accuracy of interpretation and reproducibility. However, literature provides limited data to support this assumption.

MRI Evaluation of Painful Hip Joint

Background: The hip is a stable, major weight-bearing joint with significant mobility. It can be involved by numerous pathological conditions like congenital and developmental, infective, arthritic, and neoplastic. Hence, early diagnosis and characterization of pathology play a vital role for the clinicians in proper management and follow-up of the disease. This study aimed to evaluate the role of MRI in the diagnosis of painful hip pathology. Subjects and Methods: This study was a prospective study; total 50 patients were included in this study. This study was conducted at the Department of Radio-Diagnosis, Rajindra Hospital, Patiala. MR Imaging was done with a 1.5 Tesla superconductive scanner (Siemens 1.5 T Magnetom AERA MRI Machine). Results: 26 out of 69 total hip joints affected (including bilateral) were diagnosed as avascular necrosis, 14 hips as osteoarthritis, and 10 hips as septic arthritis. Inflammatory arthritis was diagnosed in 7 hips, femoroacetabular impingement and an acetabular labral tear in 2 hips each. 2 cases were reported as normal hip joint and 1 case each was reported as a primary and metastatic tumor. Conclusion: MRI is the method of choice in characterizing the various disorders of the hip joint, and it can point out specific features leading to an accurate diagnosis of the painful hip joint.