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Montri D Wongworawat - One of the best experts on this subject based on the ideXlab platform.
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editorial comment symposium 2012 Musculoskeletal Infection society
Clinical Orthopaedics and Related Research, 2013Co-Authors: Arvind Nana, Montri D WongworawatAbstract:Interdisciplinary academic collaborations, reviews, and discussions are the mainstay of the Musculoskeletal Infection Society (MSIS). The MSIS was founded in 1989 as a multidisciplinary educational and scientific forum for clinicians and scientists. Our mission is to advance knowledge in the field of Musculoskeletal Infection and its treatment by: (1) educating clinician and research members; (2) educating the medical community and the general public; and (3) promoting and maintaining professional standards in order to provide the best professional care to patients with Musculoskeletal Infection.
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2011 Musculoskeletal Infection society editorial comment
Clinical Orthopaedics and Related Research, 2012Co-Authors: Elie F Berbari, Montri D WongworawatAbstract:In this volume of CORR® we publish 13 papers presented at the 21st Annual Meeting of the Musculoskeletal Infection Society (MSIS) held in Rochester, MN in August 2011. This special issue focuses on novel biofilm pathophysiology and cutting edge research related to the prevention, diagnosis, and management of prosthetic joint Infections. A better understanding of biofilm prevention and formation may lead to more effective management strategies in patients with Musculoskeletal Infections. The Jeannette Wilkins Award was granted to a paper describing a novel MRI technique that determined local drug distribution by using gadolinium-diethylenetriaminepentaacetate as an imaging surrogate for antimicrobials with similar diffusion characteristics in a rabbit model. One paper focused on the role of cis-2-decanoic acid (C2DA) in inhibiting the formation of Staphylococcus aureus biofilm using turbidity assay; combining C2DA with antibiotics increased the inhibitory effects, while no cytotoxic effects on fibroblasts were observed. Two papers focused on the basic science of local antibiotic delivery methods: the use of liposomal amphotericin in cement showed improved release at the expense of compressive strength; likewise, dough-phase mixing of high-dose antibiotics in cement led to improved antimicrobial delivery with associated compressive strength loss. The prevalence of methicillin-resistant S aureus colonization in elective spine surgery is reviewed in one paper, finding that the prevalence of 2.8% is similar to that of the arthroplasty population. Three papers focused on risk factors and the prevention of prosthetic joint Infection: the assessment of operating room traffic showed per-minute door opening rates of 0.65 for primary and 0.84 for revision cases; a large series of 15,222 patients found that preoperative anemia is associated with the development of prosthetic joint Infection; and even with the rise of resistant organisms, the addition of vancomycin to the routine cefazolin regimen did not reduce surgical site Infection, compared with single-agent dosing. Management strategies and the outcomes of patients with prosthetic joint Infections were described in four papers. One retrospective series evaluated the treatment of enterococcal periprosthetic joint Infection and confirmed that multiple operations may be required for Infection control. Another retrospective comparative study showed that an aggressive treatment protocol for culture-negative prosthetic joint Infections can achieve similar rates of Infection-free survival with culture-positive patients. In a retrospective series of 33 periprosthetic total hip Infections treated with prefabricated, partial load-bearing, gentamicin-impregnated hemiarthroplasty spacer, Infection-free status at the last followup after reimplantation was achieved in 93% of cases. A review of 239 two-stage total knee revision for Infection demonstrated 85% Infection-free survivorship at 5 years and 78% at 10 years. Finally, a comparative study of prosthetic knee Infection patients showed that the patients who received knee fusions had better functional outcomes when compared with those who received above-knee amputations. We hope that you find this symposium useful to your practice. Management of complex Musculoskeletal Infections requires the collaboration of an interdisciplinary team of microbiologists, infectious diseases specialists, and orthopedic and plastic surgeons. We invite you to join us for the 2013 MSIS meeting which will be held in Philadelphia, Pennsylvania. Fig. 1 Dr. Elie F. Berbari is shown. Fig. 2 Dr. Montri D. Wongworawat is shown.
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new definition for periprosthetic joint Infection from the workgroup of the Musculoskeletal Infection society
Clinical Orthopaedics and Related Research, 2011Co-Authors: Javad Parvizi, Montri D Wongworawat, Kevin Lloyd Garvin, Thomas W Bauer, Elie F Berbari, Bryan D Springer, Benjamin Zmistowski, Craig J Della Valle, Michael A Mont, Charalampos G ZalavrasAbstract:Based on the proposed criteria, definite PJI exists when: (1) There is a sinus tract communicating with the prosthesis; or (2) A pathogen is isolated by culture from at least two separate tissue or fluid samples obtained from the affected prosthetic joint; or (3) Four of the following six criteria exist: (a) Elevated serum erythrocyte sedimentation rate (ESR) and serum C-reactive protein (CRP) concentration, (b) Elevated synovial leukocyte count, (c) Elevated synovial neutrophil percentage (PMN%), (d) Presence of purulence in the affected joint, (e) Isolation of a microorganism in one culture of periprosthetic tissue or fluid, or (f) Greater than five neutrophils per high-power field in five high-power fields observed from histologic analysis of periprosthetic tissue at ×400 magnification. PJI may be present if fewer than four of these criteria are met.
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Papers Presented at the 2009 Meeting of the Musculoskeletal Infection Society: Editorial Comment
Clinical Orthopaedics and Related Research, 2010Co-Authors: John L. Esterhai, Montri D WongworawatAbstract:Musculoskeletal Infections result in considerable morbidity and mortality and lead to prolonged hospitalization and increased healthcare costs. Such Infections present a major challenge to patients, treating teams of specialists, and healthcare systems. An improved understanding of prevention, diagnosis, and treatment of these Infections is essential to enhance patient care and outcomes. With this goal in mind, the 20th annual meeting of the Musculoskeletal Infection Society of North America was held in Marina Del Rey, CA, in August 2010. The meeting included educational lectures and research papers on basic and biofilm science; risk factors; and prevention, diagnosis, and treatment of Musculoskeletal Infections. In this issue, Clinical Orthopaedics and Related Research features 11 of these papers. Four papers focus on the basic science of local antimicrobial delivery. New information is presented on elution of antimicrobials from emulsified bone cement, from bone cement of increased porosity, and from two sources of calcium sulfate as delivery vehicles. The cytotoxic effects of amphotericin B are also demonstrated. Diagnosis of Infection can be challenging, and three papers address this issue by describing the role of joint aspirate white blood cell count and neutrophil percentage in the diagnosis of periprosthetic joint Infections, by investigating the association of early postoperative leukocytosis with these Infections, and by presenting a novel molecular technique for the diagnosis of Infection. Two papers report on the management of periprosthetic joint Infections. The results of irrigation and debridement for these Infections are presented, as well as the outcome after two-stage exchange arthroplasty for infected knee arthroplasty. Finally, one paper addresses septic arthritis of a diseased hip using an articulating spacer and one reports on the sterility of the personal protection system in total joint arthroplasty. The annual meeting of the Musculoskeletal Infection Society of North America emphasizes interdisciplinary collaboration among basic scientists, infectious disease specialists, and orthopaedic surgeons and provides a unique opportunity to exchange information and learn from each other. The 2-day meeting in 2011 was held in Rochester, MN, August 5 to 6 (Figs. 1, ,22). Fig. 1 Dr. Charalampos G. Zalavras is shown. Fig. 2 Dr. Montri D. Wongworawat is shown.
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papers presented at the 2008 meeting of the Musculoskeletal Infection society editorial comment
Clinical Orthopaedics and Related Research, 2009Co-Authors: Douglas R Osmon, Montri D WongworawatAbstract:Surgical site Infections after orthopaedic surgery are a source of considerable postoperative morbidity and mortality and are associated with increased rehospitalization and higher healthcare expenditures. Patients with surgical site Infections may develop greater physical limitations that lead to reductions in health-related quality of life, particularly if they require reoperation and/or removal of an orthopaedic implant such as a joint prosthesis. While much of the science of Infection prevention and treatment has yet to be explored, there has been substantial progress in improving methods for addressing surgical site Infections. The 18th annual meeting of the Musculoskeletal Infection Society of North America was held in August 2008 at Lake Tahoe, California. In this issue, CORR features papers presented at the annual session. Three themes emerge from the series of papers—prevention, diagnosis, and treatment of Musculoskeletal Infection. Several papers focus on prevention by presenting risk factors associated with the development of surgical site Infections, including modifiable risk factors. These modifiable risk factors, such as diabetes, can be improved by patients and physicians prior to orthopaedic surgery to decrease the risk of surgical site Infection in the individual patient. The utility of specific preoperative preventive measures such as different types of barrier preparations were also discussed, as were the effect of the attachment of antibiotics to prostheses to reduce the risk of surgical site Infection on the topography of titanium alloy surfaces. The increasing use of ingrowth prostheses that do not allow for antibiotic impregnated cement makes this an important issue for future basic science and translational research. Regarding the diagnosis of Musculoskeletal Infection, the utility of MRI to improve preoperative planning in patients with Musculoskeletal Infections was reviewed. More work in this area relating to the cost effectiveness of the approach is warranted. The majority of the papers presented at the annual session discussed the treatment of Infection, with the focus on implant-related Infection. Topics range from the basic science of local antibiotic delivery to the clinical experience of major limb amputations due to uncontrolled Infection. Also addressed were important specific topics relating to the reasons for unexpected hospital readmission following discharge after treatment of Musculoskeletal Infection, and the increasing threat of antimicrobial resistance among organisms causing Musculoskeletal Infection. In this era of optimization of patient safety and Infection prevention, addressing the problem of surgical site Infections begins with careful patient selection and preoperative improvement in modifiable risk factors, proper surgical technique with meticulous environmental control, and heightened awareness for effective surveillance. Once diagnosed, successful treatment of Musculoskeletal Infection requires a team approach that employs evidence-based practices whenever possible. It is through dialogue—between orthopaedists, infectious disease specialists, and basic scientists—that we advance our understanding of Musculoskeletal Infection, its prevention, diagnosis, and treatment. We hope you enjoy and learn from the articles in the symposium as we did upon hearing them presented at the annual session in 2008. We invite you to join us for our 2009 annual meeting.
Richard A. Brand - One of the best experts on this subject based on the ideXlab platform.
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Papers Presented at the 2008 Meeting of the Musculoskeletal Infection Society: John Albert Key, 1890–1955
Clinical Orthopaedics and Related Research®, 2009Co-Authors: Richard A. BrandAbstract:This biographical sketch on John Albert Key corresponds to the historic text, The Classic: Sulfonamides in the Treatment of Chronic Osteomyelitis, available at DOI 10.1007/s11999-009-0797-7 .
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papers presented at the 2008 meeting of the Musculoskeletal Infection society john albert key 1890 1955
Clinical Orthopaedics and Related Research, 2009Co-Authors: Richard A. BrandAbstract:This biographical sketch on John Albert Key corresponds to the historic text, The Classic: Sulfonamides in the Treatment of Chronic Osteomyelitis, available at DOI 10.1007/s11999-009-0797-7.
Lawson A B Copley - One of the best experts on this subject based on the ideXlab platform.
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the epidemiology and regional burden of Musculoskeletal Infection in pediatric orthopaedics
Pediatrics, 2018Co-Authors: Ryan Koehler, Lawson A B Copley, Keith D Baldwin, Dave Spence, Joseph A Janicki, Jennifer C Laine, Ying Li, Mark J Miller, Ben Shore, Jason W StonebackAbstract:Purpose Pediatric Musculoskeletal Infection (MSKI) is a significant cause of morbidity, mortality and hospital resource utilization. Effective clinical practice guidelines are necessary to guide care and maximize the use of hospital resources. However, it is hypothesized that the burden and cause of MSKI varies widely with geography, thus may require region-specific guidelines to optimize the quality, safety, and value of care for children with MSKI. The purpose of this study was to determine the epidemiology and regional differences in burden and causative microbes in MSKI evaluated and treated by pediatric orthopaedic surgeons. Methods Seventeen CORTICES centers (Figure-1A) retrospectively reviewed a minimum of 1 year of patient charts from 2010–2016 (average 2.6 years) reporting the annual number of emergency department (ED) visits, orthopaedic consultations, MSKI-related consultations, patients with …
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key concepts of Musculoskeletal Infection
Journal of Bone and Joint Surgery American Volume, 2017Co-Authors: Scott Rosenfeld, Lawson A B Copley, Megan E Mignemi, Thomas J An, Michael A Benvenuti, Jon SchoeneckerAbstract:Over the past few decades, Musculoskeletal Infections have increased in both incidence and severity. The clinical manifestations of Musculoskeletal Infections range from isolated osteomyelitis to multisite Infections with systemic complications. Although this increased incidence of Musculoskeletal Infections correlates with the increased incidence of methicillin-resistant Staphylococcus aureus Infections, other nonresistant infectious organisms have been associated with severe Musculoskeletal Infections; this finding supports the likelihood that an antibiotic resistance profile is not a major factor in bacterial virulence. Instead, a multitude of virulence factors allow infectious organisms to manipulate and evade the immune response of the host. Organisms such as S aureus and Streptococcus pyogenes are able to hijack the acute phase response of the host, which allows for protected proliferation and dissemination. The serum factors produced by the acute phase response, including interleukin-6, C-reactive protein, erythrocytes/fibrinogen, and platelets, can be used to assess Musculoskeletal Infection severity and monitor treatment. Bacterial genome sequencing has identified virulence factors in a wide variety of clinical manifestations of Musculoskeletal Infections and may help identify targets for clinical therapy. Currently, however, the management of Musculoskeletal Infections relies on accurate organism identification and a thorough recognition of the sites of Infection and the tissues that are involved. MRI aids in the localization of Musculoskeletal Infection and identification of sites that require surgical debridement.
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Evidence-Based Treatment for Musculoskeletal Infection
Paediatric Orthopaedics, 2016Co-Authors: Megan E Mignemi, Lawson A B Copley, Jon SchoeneckerAbstract:Musculoskeletal Infection (MSKI) in children is a common cause of hospitalization in the pediatric population worldwide. Severity of disease is dependent upon the amount and type of tissue involved. Though common, pediatric MSKI diagnosis and treatment can be challenging. In this chapter, we have critically reviewed and summarized the evidence that underpin the current practice in the developed world. Evidence-based treatment guidelines applied by a multidisciplinary team resulted in better care of children with MSKI (Grade B). Non-contrasted MRI is the diagnostic modality of choice to distinguish isolated septic arthritis from adjacent Infection (Grade B). Septic arthritis is the most common diagnosis with synovial fluid WBC counts between 25,000 and 75,000 cells/mm3 and can be adequately treated by both arthroscopy or traditional arthrotomy (Grade B). Acute haematogenous osteomyelitis (AHO) can be treated with short course of IV antibiotic, followed by oral antibiotic for 3–4 weeks (Grade B).
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a novel classification system based on dissemination of Musculoskeletal Infection is predictive of hospital outcomes
Journal of Pediatric Orthopaedics, 2016Co-Authors: Megan E Mignemi, Lawson A B Copley, Thomas J An, Michael A Benvenuti, Gregory A Mencio, Jeffrey E Martus, Stephen A Lovejoy, Isaac P Thomsen, Derek J Williams, Jon SchoeneckerAbstract:Background: Musculoskeletal Infections (MSKIs) are a common cause of pediatric hospitalization. Children affected by MSKI have highly variable hospital courses, which seem to depend on Infection severity. Early stratification of Infection severity would therefore help to maximize resource utilization and improve patient care. Currently, MSKIs are classified according to primary diagnoses such as osteomyelitis, pyomyositis, etc. These diagnoses, however, do not often occur in isolation and may differ widely in severity. On the basis of this, the authors propose a severity classification system that differentiates patients based on total Infection burden and degree of dissemination. Methods: The authors developed a classification system with operational definitions for MSKI severity based on the degree of dissemination. The operational definitions were applied retrospectively to a cohort of 202 pediatric patients with MSKI from a tertiary care children’s hospital over a 5-year period (2008 to 2013). Hospital outcomes data [length of stay (LOS), number of surgeries, positive blood cultures, duration of antibiotics, intensive care unit LOS, number of days with fever, and number of imaging studies] were collected from the electronic medical record and compared between groups. Results: Patients with greater Infection dissemination were more likely to have worse hospital outcomes for LOS, number of surgeries performed, number of positive blood cultures, duration of antibiotics, intensive care unit LOS, number of days with fever, and number of imaging studies performed. Peak C-reactive protein, erythrocyte sedimentation rate, white blood cell count, and temperature were also higher in patients with more disseminated Infection. Conclusions: The severity classification system for pediatric MSKI defined in this study correlates with hospital outcomes and markers of inflammatory response. The advantage of this classification system is that it is applicable to different types of MSKI and represents a potentially complementary system to the previous practice of differentiating MSKI based on primary diagnosis. Early identification of disease severity in children with MSKI has the potential to enhance hospital outcomes through more efficient resource utilization and improved patient care. Level of Evidence: Level II—prognostic study.
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sequential parenteral to oral clindamycin dosing in pediatric Musculoskeletal Infection a retrospective review of 30 mg kg d versus 40 mg kg d
Pediatric Infectious Disease Journal, 2016Co-Authors: Cole M Erickson, Chan Hee Jo, Eduardo A Lindsay, Kyana Stewart, Michelle I Thomas, Lawson A B CopleyAbstract:Background:Children with Musculoskeletal Infection in methicillin-resistant Staphylococcus aureus (MRSA) prevalent communities are often treated with oral clindamycin. Current guidelines recommend approximately 40 mg/kg/d for MRSA Infections. This study investigates the clinical practice of using 30
Javad Parvizi - One of the best experts on this subject based on the ideXlab platform.
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Musculoskeletal Infection in Pediatrics: Assessment of the 2018 International Consensus Meeting on Musculoskeletal Infection.
The Journal of bone and joint surgery. American volume, 2019Co-Authors: Alexus M Cooper, Alexander J Shope, Mahzad Javid, Ali Parsa, Muhammad Amin Chinoy, Javad ParviziAbstract:The Second International Consensus Meeting (ICM) on Musculoskeletal Infection was held in July 2018 in Philadelphia, Pennsylvania. This meeting involved contributions from an international multidisciplinary consortium of experts from orthopaedic surgery, infectious disease, pharmacology, rheumatology, microbiology, and others. Through strict delegate engagement in a comprehensive 13-step consensus process based on the Delphi technique, evidence-based consensus guidelines on Musculoskeletal Infection were developed. The 2018 ICM produced updates to recommendations from the inaugural ICM that was held in 2013, which primarily focused on periprosthetic Infection of the hip and the knee, and added new guidelines with the expansion to encompass all subspecialties of orthopaedic surgery. The following proceedings from the pediatrics section are an overview of the ICM consensus recommendations on the prevention, diagnosis, and treatment of pediatric Musculoskeletal Infection.
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leukocyte esterase strip test matched for Musculoskeletal Infection society criteria
Journal of Bone and Joint Surgery American Volume, 2014Co-Authors: Eric H Tischler, Priscilla K Cavanaugh, Javad ParviziAbstract:Background: The presence of leukocyte esterase in the synovial fluid has recently been proposed as a marker for periprosthetic joint Infection. However, the sensitivity and specificity of leukocyte esterase has not been determined when matched for the current, most inclusive Musculoskeletal Infection Society (MSIS) criteria for periprosthetic joint Infection. Methods: The presence of leukocyte esterase was prospectively evaluated in synovial joint aspirates from hips and knees from May 2009 to May 2013. The cohort consisted of 189 hip and knee aspirations (fifty-two positive and 137 negative for Infection). If the aspirate was bloody, a centrifuge was used to precipitate red blood cells and obtain clear synovial fluid. A standard chemical test strip (graded as negative, trace, +, or ++) was used to detect the presence of leukocyte esterase. The sensitivity, specificity, positive predictive value, and negative predictive value of the leukocyte esterase strip test were calculated using ++ and ++/+ as two positive strip result scenarios. Results: Synovial fluid was obtained from 221 joints that underwent revision total hip or total knee arthroplasty for either mechanical failure or periprosthetic Infection. Due to the lack of adequate criteria for MSIS criteria classification, thirty-two joints were excluded. The leukocyte esterase test with a threshold of +/++ had a sensitivity, specificity, positive predictive value, and negative predictive value of 79.2% (95% confidence interval [CI], 65.9% to 89.2%), 80.8% (95% CI, 73.3% to 87.1%), 61.8% (95% CI, 49.2% to 73.3%), and 90.1% (95% CI, 84.3% to 95.4%), respectively. Using the ++ as a positive leukocyte esterase result, the sensitivity, specificity, positive predictive value, and negative predictive value were 66.0% (95% CI, 51.7% to 78.5%), 97.1% (95% CI, 92.6% to 99.2%), 89.7% (95% CI, 75.8% to 97.1%), and 88.0% (95% CI, 81.7% to 92.7%), respectively. Conclusions: When matched to the current MSIS criteria, the leukocyte esterase strip test yielded a high specificity, positive predictive value, negative predictive value, and moderate sensitivity. These results demonstrate that leukocyte esterase is an accurate, effective marker of periprosthetic joint Infection as defined by the MSIS criteria. The leukocyte esterase strip test is a valuable tool that can be used in conjunction with the current battery of diagnostic tests available. Level of Evidence: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Diagnosing Periprosthetic Joint Infection: Has the Era of the Biomarker Arrived?
Clinical Orthopaedics and Related Research, 2014Co-Authors: Carl Deirmengian, Keith Kardos, Patrick Kilmartin, Alexander Cameron, Kevin Schiller, Javad ParviziAbstract:BACKGROUND: The diagnosis of periprosthetic joint Infection (PJI) remains a serious clinical challenge. There is a pressing need for improved diagnostic testing methods; biomarkers offer one potentially promising approach. QUESTIONS/PURPOSES: We evaluated the diagnostic characteristics of 16 promising synovial fluid biomarkers for the diagnosis of PJI. METHODS: Synovial fluid was collected from 95 patients meeting the inclusion criteria of this prospective diagnostic study. All patients were being evaluated for a revision hip or knee arthroplasty, including patients with systemic inflammatory disease and those already receiving antibiotic treatment. The Musculoskeletal Infection Society (MSIS) definition was used to classify 29 PJIs and 66 aseptic joints. Synovial fluid samples were tested by immunoassay for 16 biomarkers optimized for use in synovial fluid. Sensitivity, specificity, and receiver operating characteristic curve analysis were performed to assess for diagnostic performance. RESULTS: Five biomarkers, including human alpha-defensin 1-3, neutrophil elastase 2, bactericidal/permeability-increasing protein, neutrophil gelatinase-associated lipocalin, and lactoferrin, correctly predicted the MSIS classification of all patients in this study, with 100% sensitivity and specificity for the diagnosis of PJI. An additional eight biomarkers demonstrated excellent diagnostic strength, with an area under the curve of greater than 0.9. CONCLUSIONS: Synovial fluid biomarkers exhibit a high accuracy in diagnosing PJI, even when including patients with systemic inflammatory disease and those receiving antibiotic treatment. Considering that these biomarkers match the results of the more complex MSIS definition of PJI, we believe that synovial fluid biomarkers can be a valuable addition to the methods utilized for the diagnosis of Infection. LEVEL OF EVIDENCE: Level II, diagnostic study. See Instructions for Authors for a complete description of levels of evidence.
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new definition for periprosthetic joint Infection from the workgroup of the Musculoskeletal Infection society
Clinical Orthopaedics and Related Research, 2011Co-Authors: Javad Parvizi, Montri D Wongworawat, Kevin Lloyd Garvin, Thomas W Bauer, Elie F Berbari, Bryan D Springer, Benjamin Zmistowski, Craig J Della Valle, Michael A Mont, Charalampos G ZalavrasAbstract:Based on the proposed criteria, definite PJI exists when: (1) There is a sinus tract communicating with the prosthesis; or (2) A pathogen is isolated by culture from at least two separate tissue or fluid samples obtained from the affected prosthetic joint; or (3) Four of the following six criteria exist: (a) Elevated serum erythrocyte sedimentation rate (ESR) and serum C-reactive protein (CRP) concentration, (b) Elevated synovial leukocyte count, (c) Elevated synovial neutrophil percentage (PMN%), (d) Presence of purulence in the affected joint, (e) Isolation of a microorganism in one culture of periprosthetic tissue or fluid, or (f) Greater than five neutrophils per high-power field in five high-power fields observed from histologic analysis of periprosthetic tissue at ×400 magnification. PJI may be present if fewer than four of these criteria are met.
Christopher Palestro - One of the best experts on this subject based on the ideXlab platform.
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radionuclide imaging of Musculoskeletal Infection a review
The Journal of Nuclear Medicine, 2016Co-Authors: Christopher PalestroAbstract:There are numerous imaging tests for diagnosing Musculoskeletal Infection. Radiographs are routinely performed, because even when not diagnostic, they provide an anatomic overview of the region of interest that could influence subsequent procedure selection and interpretation. MRI is sensitive and provides superb anatomic detail. Bone scintigraphy accurately diagnoses osteomyelitis in bones not affected by underlying conditions. (67)Ga is used primarily for spondylodiskitis. Although in vitro labeled leukocyte imaging is the radionuclide test of choice for complicating osteomyelitis such as diabetic pedal osteomyelitis and prosthetic joint Infection, it is not useful for spondylodiskitis. Antigranulocyte antibodies and antibody fragments have limitations and are not widely available. (111)In-biotin is useful for spondylodiskitis. Radiolabeled synthetic fragments of the antimicrobial peptide ubiquicidin are promising Infection-specific agents. (18)F-FDG is the radiopharmaceutical of choice for spondylodiskitis. Its role in diabetic pedal osteomyelitis and prosthetic joint Infection is not established. Preliminary data suggest (68)Ga may be useful in Musculoskeletal Infection. (124)I-fialuridine initially showed promise as an Infection-specific radiopharmaceutical, but subsequent investigations were disappointing. The development of PET/CT and SPECT/CT imaging systems, which combine anatomic and functional imaging, has revolutionized diagnostic imaging. These hybrid systems are redefining the diagnostic workup of patients with suspected or known Infection and inflammation by improving diagnostic accuracy and influencing patient management.
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Multiagent imaging of inflammation and Infection with radionuclides
Clinical and Translational Imaging, 2013Co-Authors: Christopher Palestro, Andor W. J. M. Glaudemans, Rudi A. J. O. DierckxAbstract:Molecular imaging with single photon- and positron-emitting tracers plays an important role in the evaluation of inflammation and Infection. Although supplanted by labeled leukocyte imaging for most indications, gallium-67 remains useful for opportunistic Infections, pulmonary inflammation and interstitial nephritis and, when [^18F]FDG is not available, spinal Infection and fever of unknown origin. In vitro labeled leukocyte imaging is the radionuclide procedure of choice for most Infections in immunocompetent patients. When performed for Musculoskeletal Infection, complementary bone marrow imaging usually is necessary. Recent data suggest that dual time point imaging might be an alternative to marrow imaging. Several methods of labeling leukocytes in vivo, with agents including antigranulocyte antibodies and antibody fragments, peptides and cytokines, have been investigated, with variable results. These agents are not widely available and none of them are available in the USA. Radiolabeled antibiotics have been investigated as “Infection-specific” tracers, but the results to date have been disappointing. Conversely, radiolabeled antimicrobial peptides do hold promise as Infection-specific tracers. The use of positron-emitting tracers for diagnosing inflammation and Infection has generated considerable interest. [^18F]FDG is useful in fever of unknown origin, spinal osteomyelitis, vasculitis and sarcoidosis. Other positron-emitting tracers that have been investigated include [^18F]FDG-labeled leukocytes, copper-64-labeled leukocytes, gallium-68 citrate and iodine-124 FIAU. Although radiolabeled tracers are used primarily for diagnosis, they also offer objective biomarkers for assessing response to therapeutic interventions in inflammatory diseases. They could also potentially be used to target cells and molecules with specific receptor expression for histological characterization, select patients for receptor-targeted therapy and predict response to treatment.
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FDG-PET in Musculoskeletal Infections
Seminars in Nuclear Medicine, 2013Co-Authors: Christopher PalestroAbstract:Diagnosing Musculoskeletal Infection is challenging and imaging procedures are part of the diagnostic workup. Although the most commonly performed radionuclide procedures include bone, gallium-67, and labeled leukocyte imaging, FDG-PET (PET/CT) is assuming an increasingly important role in the diagnostic workup of Musculoskeletal Infection. FDG offers advantages over conventional radionuclide techniques. PET, a high-resolution tomographic technique, facilitates precise localization of abnormalities. Semiquantitative analysis potentially could be used to differentiate infectious from noninfectious conditions and monitor response to treatment. FDG is a small molecule entering poorly perfused regions rapidly; the procedure is completed in hours not days. Degenerative changes usually show faintly increased FDG uptake. FDG uptake usually normalizes within 3-4 months following trauma or surgery. Sensitivities higher than 95% and specificities ranging from 75% to 99% have been reported in acute and subacute bone and soft tissue Infection. The test is also useful for diagnosing chronic and low-grade Infection because FDG accumulates in activated macrophages. No one tracer is equally efficacious in all regions of the skeleton and the utility of FDG varies with the indication. One area in which FDG imaging clearly is useful, and should be the radionuclide study of choice, is in the evaluation of spinal osteomyelitis. The test has a high negative predictive value and is a useful adjunct to MRI for differentiating degenerative from infectious end plate abnormalities. The role of FDG imaging in the evaluation of diabetic foot Infection has yet to be clarified, with some investigators reporting high accuracy and others reporting just the opposite. Although initial investigations suggested that FDG accurately diagnoses lower extremity joint-replacement Infection subsequent studies indicate that this test cannot differentiate aseptic loosening from Infection. This is not surprising because aseptic loosening and Infection both can be accompanied by an intense inflammatory reaction. A recent meta-analysis found that the sensitivity and specificity of FDG-PET for diagnosing lower extremity prosthetic joint Infection was 87% and 82%, respectively, lower than what has been reported for combined leukocyte-marrow imaging over the past 30 years. Data about FDG-PET in septic arthritis are limited. FDG accumulates in inflammatory arthritis and its role for diagnosing septic arthritis likely would be limited.
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radionuclide imaging of Musculoskeletal Infection conventional agents
Seminars in Musculoskeletal Radiology, 2007Co-Authors: Christopher Palestro, Charito LoveAbstract:The diagnosis of Musculoskeletal Infection can be clinically challenging, and radionuclide imaging is often performed as part of the diagnostic workup. Conventional studies include bone scan, gallium imaging, and labeled leukocyte imaging. No single test is equally efficacious in all situations, and thus the procedure(s) performed should be optimized for the individual patient. Three-phase bone imaging, readily available and relatively inexpensive, is very accurate in unviolated bone. In the setting of underlying osseous abnormalities, however, the specificity of the test decreases. Four-phase bone, sequential bone/gallium, and labeled leukocyte imaging all have been used in an effort to enhance specificity. Labeled leukocyte imaging is the radionuclide procedure of choice for diagnosing so-called complicating osteomyelitis such as infected joint prostheses, diabetic pedal osteomyelitis, and Infection of the neuropathic joint. To maximize the accuracy of the study, complementary bone marrow imaging often must be performed. Labeled leukocyte imaging is of limited value in spinal osteomyelitis, however, because this entity often presents as a nonspecific photopenic defect on white cell studies. The conventional radionuclide study for evaluating spinal osteomyelitis is gallium imaging, which should be performed regardless of the findings on a contemporaneous bone scan. The reasons for this are as follows: Gallium improves the specificity of the bone scan; gallium detects accompanying soft tissue Infection, whereas the bone scan does not, and gallium may be more sensitive than the bone scan in elderly patients.
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radionuclide imaging of Musculoskeletal Infection
Brazilian Archives of Biology and Technology, 2007Co-Authors: Christopher Palestro, Charito LoveAbstract:Radionuclide imaging studies are routinely used to evaluate patients suspected of having Musculoskeletal Infection. Three-phase bone imaging is readily available, relatively inexpensive, and very accurate in the setting of otherwise normal bone. Labeled leukocyte imaging should be used in cases of "complicating osteomyelitis" such as prosthetic joint Infection. This test also is useful in clinically unsuspected diabetic pedal osteomyelitis as well as in the neuropathic joint. It is often necessary, however, to perform complementary bone marrow imaging, to maximize the accuracy of labeled leukocyte imaging. In contrast to other regions in the skeleton, labeled leukocyte imaging is not useful for diagnosing spinal osteomyelitis. At the moment, gallium is the preferred radionuclide procedure for this condition and is a useful adjunct to magnetic resonance imaging. FDG-PET likely will play an important role in the evaluation of Musculoskeletal Infection, especially spinal osteomyelitis, and may replace gallium imaging for this purpose.
