Isotope scanning in the “irritable hip syndrome”

A study of isotope scanning in children with irritable hip syndrome has demonstrated its role as a discriminator between Perthes disease and transient synovitis. Three children with normal radiographs had Perthes changes on scanning and went on to develop X-ray changes. An anatomical and pathological basis for the scan abnormalities is suggested.     

The role of ultrasound and isotope scanning in the management of irritable hips.

Patients (n = 181) with the irritable hip syndrome were reviewed. Four of these were found to have Perthes disease and 3 cases had septic arthritis. Ultrasonography provides accurate information as to the presence or absence of an effusion in children with an irritable hip syndrome. The likelihood of a positive result is higher in the early course of the disease process (i.e. within 3 days). Bone scanning, if done routinely will help in the early diagnosis of Perthes disease. Recurrence of the symptoms occurred in 18% of patients and most of them were within 12 months of the first onset of symptoms.     

Nuclear medicine studies in evaluation of skeletal lesions in children with histiocytosis X

Radiographs were compared with 99mTc scans of the bones and bone marrow as well as 67Ga-citrate scans to evaluate their sensitivity in identifying skeletal lesions in 21 children with histiocytosis X. Seven of 20 bone scans were completely normal in patients with extensive radiographic evidence of skeletal disease. In only one patient were bone scan changes demonstrated prior to radiographic abnormalities. None of the lesions was "cold" on the bone scans. 99mTc-sulfur colloid bone marrow scans and 67Ga-citrate whole-body scans were not valuable. Radiographic survey of the skeleton should be the primary diagnostic test employed in patients with histiocytosis X who have suspected skeletal lesions. Bone scans should be obtained only when the radiographs are normal or equivocal.     

Sport bei Hüftgelenkserkrankungen im Kindes- und Jugendalter

Children and adolescents suffering from hip disorders are often compromised in their physical activity and sports. The typical hip diseases in this age group are hip dysplasia, Perthes disease, Slipped Capital Femoral Epiphysis and transient synovitis of the hip. On the one hand athletic overuse can provoke hip symptoms and on the other hand sports activities need to be restricted in ongoing or past hip diseases. It is important to follow patients until growth arrest to recognize and possibly treat secondary hip deformities and early osteoarthritis.     

A case of non-malignant multifocal lesions on the methyl diphosphonate technetium-99m bone scan with enteropathy. SAPHO syndrome

This is a case of a 24-year-old man with non-malignant multifocal bone lesions on the methyl diphosphonate technetium-99m bone scan, that may represent a variant of synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome. The patient complained for diffuse osseous pain, focused mainly in the hip joints. X-rays of the hips were normal but X-rays of the shoulders showed hyperostosis of the right clavicle with no erosions. SAPHO is a rare syndrome of unknown aetiology with no more than a hundred cases reported during the last 10 years. Its typical form consists of characteristic painful osteoarticular manifestations and dermatological findings. In a variant of this syndrome, such as in our case, dermatological manifestations may be absent, but hyperostosis with osseous hypertrophy and enteropathy are present. No other malignant or benign disease was diagnosed. All routine laboratory tests for an inflammatory rheumatoid disease were negative. Treatment with non steroid anti-inflammatory agents was successful and after six months, there were no clinical symptoms and lesions on the bone scan faded. Four years later the patient remained free from symptoms. We discuss the scintigraphic, radiological laboratory clinical findings, the therapeutic criterion and the exclusion of any malignant or other benign bone disease that suggest the diagnosis of SAPHO syndrome. In conclusion, although we were unable to perform a bone biopsy, we suggest that no other diagnosis but an enteropathic variant of SAPHO syndrome may better describe the above clinical and laboratory findings. Bone scan findings have a principal diagnostic role in SAPHO syndrome.     

Skeletal assessment in neuroblastoma--the pitfalls of iodine-123-MIBG scans

This study was carried out to compare iodine-123 metaiodobenzylguanidine ([I123I]MIBG) and technetium-99m-methylene diphosphonate bone scans (99mTc-MDP) in the detection of skeletal involvement by neuroblastoma. Forty-four children with neuroblastoma underwent both [123I] MIBG and 99mTc-MDP scans within a 4-wk period; bone marrow examination also was performed; all these investigations were done both at diagnosis and at follow-up. At diagnosis, four children with Stage 4 disease had normal [123I]MIBG scans but abnormal 99mTc-MDP scans, while at follow-up there were four children with negative [123I]MIBG studies who later died from disseminated neuroblastoma. All eight scans are considered false-negative. In 24 children, the [123I]MIBG revealed more extensive disease with 161 positive sites while the 99mTc-MDP scan showed only 100 positive sites; 34 of these sites were common to both studies. This study shows that underassessment of skeletal involvement by neuroblastoma occurred using [123I]MIBG scans and that one cannot therefore substitute [123I]MIBG for 99mTc-MDP bone scans in the staging of neuroblastoma.     

Osteitis Pubis in a Basketball Player

In brief:An 18-year-old male varsity basketball player complained of lower left abdominal pain of a month's duration. Laboratory tests were normal, and no hernia was present. A computed tomography scan showed no abnormality, and fraying of the pubic bone along the symphysis was too subtle to detect on x-ray. A bone scan (pelvic views), however, confirmed a diagnosis of osteitis pubis. Although this disease is self-limited, the patient was treated with corticosteroids and anti-inflammatory medication to enhance his comfort. His condition gradually improved within a few months, and he returned to competition the following season. Follow-up bone scans at one and two years were normal.     

Consecutive bone scintigraphy in bilateral hip migratory transient osteoporosis

A 34-year-old male was seen with severe right hip pain, rapidly worsening in 1 to 2 weeks, with no history of trauma. There was no fever and laboratory studies were normal. Bone scan showed markedly increased uptake in the femoral head. Magnetic resonance imaging showed bone marrow edema. The patient became asymptomatic with conservative therapy, confirmed by returning toward normal on bone scintigraphy 5 months later. He was readmitted 4 months later because the patient developed similar symptoms on the opposite side. A bone scan showed demineralization of the left femoral head. He recovered on conservative therapy and there was a normal bone scan one year after the initial admission.     

The use of [18 F]fluorodeoxyglucose positron emission tomography to differentiate between synovitis,loosening and infection of hip and knee prostheses

Pain is a common unspecific symptom in orthopaedic prosthetics. The accurate differentiation between synovitis, loosening or infection is often difficult with conventional X-rays, arthrography or bone scintigraphy. Because of the high glucose uptake of inflammatory cells, [18F]fluorodeoxyglucose (18F-FDG) is an appropriate tracer for the evaluation of suspected inflammation or infection. In this preliminary study we describe 18F-FDG PET findings in patients referred for evaluation of painful hip or knee prostheses. We studied 23 patients with 28 prostheses, 14 hip and 14 knee prostheses, who had a complete operative or clinical follow-up. 18F-FDG PET scans were obtained with an ECAT EXACT HR+ PET scanner. High glucose uptake in the bone prostheses interface was considered as positive for infection, an intermediate uptake as suspect for loosening, and uptake only in the synovia was considered as synovitis. The imaging results were compared with operative findings or clinical outcome. PET correctly identified three hip and one knee prostheses as infected, two hip and two knee prostheses as loosening, four hip and nine knee prostheses as synovitis, and two hip and one knee prostheses as unsuspected for loosening or infection. In three patients covered with an expander after explantation of an infected prosthesis PET revealed no further evidence of infection in concordance with the clinical follow-up. PET was false negative for loosening in one case. Our preliminary results suggest that FDG PET could be a useful tool for differentiating between infected and loose orthopaedic prostheses as well as for detecting only inflammatory tissue such as synovitis.     

Comparison of FDG-PET and Bone Scans for Detecting Skeletal Metastases in Patients with Non-small Cell Lung Cancer

Purpose: Positron Emission Tomography (PET) with F18-fluorodeoxyglucose has been proven useful for staging non-small cell lung cancer. Bone scans are frequently performed for suspected skeletal metastases. The purpose of this study was to evaluate if bone scans compared to PET scans provide additional information that changes the stage of disease.Procedures: Nineteen patients with non-small cell lung cancer had PET and bone scans done for staging of the malignancy. The results of both studies were compared.Results: Bone and PET scans agreed on the presence or absence of skeletal metastases in all nineteen patients. The addition of a bone scan to a PET scan did not change the stage of the disease or the management in any of the patients. Bone scans allowed for more precise localization of the lesions in some patients.Conclusions: Bone scans do not change the stage of disease when performed in addition to PET scans, but provide more precise localization of skeletal abnormalities.     

Radionuclide liver and bone scanning in the evaluation of patients with endometrial carcinoma

Staging bone scans or skeletal surveys were obtained of 97 patients with endometrial carcinoma. Of the 77 patients with Stage I or II disease, no metastases were identified at staging. Three patients in the entire series demonstrated bony metastases; all of these metastases were detectable by radionuclide bone scan and radiographic bone survey. Eighty-nine patients were examined with radionuclide liver/spleen scanning at the time of staging. Four of the 89 initial scans were interpreted as demonstrating hepatocellular disease, and all four patients had abnormal liver function studies. Only one patient demonstrated a possible hepatic metastasis at initial diagnosis. This patient also had abnormal liver function studies. Based on these results, bone surveys and radionuclide bone scans are not indicated as screening procedures in endometrial carcinoma. It is suggested that screening for liver metastases in patients with endometrial carcinoma is not warranted in patients with normal liver function studies.     

Role of skeletal scintigraphy in advanced retinoblastomas

PURPOSE: To document the incidence of skeletal metastases exclusively in advanced cases of retinoblastoma and to rationalize the use of preoperative skeletal scintigraphy in such patients. MATERIAL AND METHODS: Preoperative bone scans of 36 consecutive patients with advanced retinoblastoma who underwent skeletal scintigraphy during 1998 to 2003 were analyzed retrospectively. Bone scans were classified as: Grade 1 (high probability scan for skeletal metastases), Grade 2 (equivocal malignant or benign abnormalities), or Grade 3 (normal or certainly benign lesions). RESULTS: Grade 1 scan was found in 3 (8.33%) patients; bone metastases were confirmed by additional investigations. Grade 2 scan was found in 5 (13.88%) patients; bone metastases were excluded in all by additional investigations. Grade 3 scan was found in the remaining 28 (77.77%) patients. Extraorbital extension of disease was demonstrated by fine needle aspiration of lymph nodes in five patients, which included all three patients with Grade 1 scan. In addition to lymph node metastases, two patients had intracranial extension of the disease; demonstrated by contrast-enhanced magnetic resonance imaging of the head. One patient had liver metastases detected on abdominal ultrasound. None of the patients had skeletal metastases only. CONCLUSION: Routine preoperative bone scan is not justified in patients with locally advanced retinoblastoma. Bone scan should only be performed in patients with documented extraocular metastatic disease.     

Asymptomatic total hip prosthesis: natural history determined using Tc- 99m MDP bone scans

A prospective study was performed with 97 patients who had undergone total hip replacement surgery and who were not experiencing pain or other symptoms or problems. The study was intended to determine the normal postoperative appearance of radionuclide scans of the hip following administration of technetium-99m methylene diphosphonate. Five areas of the prostheses were evaluated. Results showed that 6 months after implantation activity around the lesser trochanter and prosthesis shaft became insignificant. Activity around the acetabulum, greater trochanter, and prosthesis tip stabilized approximately 2 years after surgery; approximately 10% of patients in the study had persistent activity in these areas. Familiarity with this normal progression is fundamental to interpretation of postoperative bone scans in patients with total hip prosthesis.     

Scintigraphic patterns of the reflex sympathetic dystrophy syndrome of the lower extremities

Thirty-two patients with clinical signs and symptoms of the reflex sympathetic dystrophy syndrome (RSDS) of the lower extremities underwent Tc-99m MDP bone scintigraphy. Twenty-three patients had abnormal scan findings consistent with RSDS, while the scans of the remaining nine patients were normal. Of the 23 patients with abnormal scans, 19 demonstrated increased periarticular activity on early and delayed images, while 4 patients demonstrated decreased activity in the affected limb.     

99Tcm-MDP, 67Ga-citrate and 111In-leucocytes for detecting prosthetic hip infection

An assessment was made of the roles of 99Tcm-MDP, 67Ga-citrate and 111In-leucocytes in identifying infected hip prostheses. Fifty painful prosthetic hips were investigated with a 99Tcm-MDP bone scan and an 111In-labelled leucocyte scan (ILLS). In 32 cases, a 67Ga-citrate scan was also performed. Normal or focal MDP uptake was obtained only in uninfected hips. Diffuse uptake of MDP was obtained only in infected hips and in one case of non-septic synovitis which also produced a false positive ILLS. A focal MDP uptake superimposed on a diffuse pattern was obtained in both infected and uninfected hips. The ILLS was abnormal in eight out of 11 cases of infection and in two out of 39 cases without infection. The 67Ga scan was abnormal in five out of six cases of infection and in five out of 26 cases without infection. It was concluded that a 99Tcm bone scan should be performed first on a painful prosthetic hip, and that for detecting infection, an ILLS was more specific but less sensitive than a 67Ga-citrate scan.     

Radiographic and scintigraphic skeletal imaging in patients with neuroblastoma: concise communication

Bone scans, bone-marrow scans, and radiographic skeletal surveys have been reviewed in 40 children with neuroblastoma. Bone scans are the most sensitive method for detecting metastases and should be used first. The additional yield from a skeletal survey is very small, so it should be done only if the bone scan is negative and major therapeutic decisions are to be made. Bone-marrow scans provide a sensitive method of identifying metastases, and may help in staging a patient as stage IV when the bone scan is negative.     

Technical note: identifying the prostate cancer 'superscan' by quantitative skeletal scintigraphy

AIM: The risk of failing to recognize the false, normal pattern of the superscan is a real one, with potential consequences for diagnosis and treatment. Quantitative indices of bone activity have previously measured uptake ratios or exposure time. Such estimates from spot images have provided differentiation of the superscan from normal. More recent reports describe quantitative methods for scanning type gamma-cameras, relying upon significant computation, availability of image analysis programmes or the drawing of whole skeletal regions of interest. The aim of this study was to establish a set of reference values for the evaluation of skeletal scintigraphy images, using the whole-body count alone. MATERIALS AND METHODS: Patients underwent a routine whole-body bone study using the scanning technique. The total counts acquired during the scan were used to compare the skeletal uptake of the radiopharmaceutical between prostate patients showing superscan image patterns (n=38), prostate cancer patients with normal scans (n=40) and a control group (n=40) with normal scans, referred for reasons other than prostate cancer. RESULTS: Qualitative comparison showed patterns of avid bone uptake with diminished visualization of kidney and bladder activity in the superscan group, and normal scans in the control and prostate patient groups. Quantitation using total counts recorded directly from the whole-body bone scan showed a significantly raised value in the superscan group only (P<0.001). We have established a simple set of objective reference bands to complement visual interpretation of the scan. CONCLUSION: The whole-body image count alone, with little or no additional processing, is a helpful discriminator for the nuclear medicine superscan. This may assist the identification of this relatively uncommon diffuse metastatic disease in men with prostate cancer and reduce the number of investigations that might otherwise be reported incorrectly as normal.     

Scintigraphic patterns in osteoid osteoma and spondylolysis

A retrospective review was performed of radionuclide bone scans and radiographs of 54 children with diagnoses of spondylolysis or osteoid osteoma/osteoblastoma. The findings indicate that skeletal scintigraphy shows imaging patterns that can be used to help distinguish these two conditions. Most cases of spondylolysis and all cases of osteoid osteoma or osteoblastoma demonstrated focally increased activity on the delayed skeletal scintigrams. Evaluation of the bone scan images obtained during the immediate postinjection period revealed intense activity with osteoid osteoma and osteoblastoma, but minimal or no abnormal activity in cases of spondylolysis. In addition, spondylolysis was the only condition that produced bilateral abnormalities in the pars interarticularis region in these children.     

Sonography of the painful hip in children: 500 consecutive cases

Five hundred children with a painful hip or a limp were evaluated prospectively by plain films and sonography. The clinical, radiographic, and sonographic findings were correlated with the final diagnoses. Sonography disclosed hip effusion in 235 patients, and plain films were abnormal in 58 of these 235 patients and in four others. Both sonography and plain films were normal in 261 patients. No sonographic signs served to differentiate sterile, purulent, or hemorrhagic effusion. Follow-up sonograms were performed in 202 patients. Sonography showed that 73% of patients with presumed transient synovitis had no effusion 2 weeks after diagnosis. Patients with hip disorders other than transient synovitis had persistent effusion for more than 2 weeks; however, that was also observed in 27% of patients with presumed transient synovitis. Sonography was more sensitive than plain films for detecting hip effusion. However, sonographic detection of effusion changed the therapeutic approach in only six patients.     

Bone scintigraphy in preschool children with lower extremity pain of unknown origin.

Small children often cannot describe the location of bone pain for parents or physicians. Bone scans were performed in 56 children under five years of age with lower extremity pain and/or gait abnormalities of unknown etiology. Patients with fever, and those known to have infection, child abuse, malignancy, and/or radiographic abnormalities were excluded. Thirty patients had abnormal bone scans. Abnormalities included evidence of hip synovitis (4), femoral head avascularity (2), various proximal femoral abnormalities (3), knee synovitis (3), toddler's fracture (1), various tibial or fibular abnormalities (4), and various abnormalities of the tarsal bones (16). Tarsal bone abnormalities included four with abnormal calcaneal uptake and nine with abnormal uptake in or adjacent to the cuboid bone. Correlative imaging studies were available for 26 sites, and focal bone findings were noted at only five locations. Tarsal bone abnormalities accounted for over half of the scintigraphic abnormalities in these preschool children with gait abnormalities. Abnormal uptake in/or adjacent to the cuboid bone was common and probably represented stress injury.