(Radiographics. 2001;21:1229-1238.)
© RSNA, 2001
Role of Nuclear Medicine in Diagnosis of the Infected Joint Replacement1
Charito Love, MD,
Maria B. Tomas, MD,
Scott E. Marwin, MD,
Paul V. Pugliese, RT and
Christopher J. Palestro, MD
1 From the Division of Nuclear Medicine (C.L., M.B.T., P.V.P., C.J.P.) and Department of Orthopedic Surgery (S.E.M.), Long Island Jewish Medical Center, 270-05 76th Ave, New Hyde Park, NY 11040. Presented as an education exhibit at the 2000 RSNA scientific assembly. Received March 14, 2001; revision requested April 25 and received May 9; accepted May 9. C.J.P. receives research grants and has received honoraria from Palatin Technologies, Princeton, NJ. Address correspondence to C.L. (e-mail: love@lij.edu).
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Abstract
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Some complications of joint replacement surgery are easily diagnosed; however, differentiating infection from aseptic loosening is difficult because these entities are remarkably similar at clinical and histopathologic examination. Clinical signs and symptoms, laboratory tests, radiography, and joint aspiration are insensitive, nonspecific, or both. Cross-sectional imaging modalities are hampered by artifacts produced by the prosthetic devices themselves. Radionuclide imaging is not affected by the presence of metallic hardware and is therefore useful for evaluating the painful prosthesis. Bone scintigraphy is useful as a screening test, despite an accuracy of only 50%–70%, because normal results essentially exclude a prosthetic complication. The addition of gallium-67, a nonspecific inflammation-imaging agent, improves the accuracy of bone scintigraphy to 70%–80%. The accuracy of combined leukocyte-marrow imaging, 90%, is the highest among available radionuclide studies. Its success is due to the fact that leukocyte imaging is most sensitive for detection of neutrophil-mediated inflammation (ie, infection). The success of leukocyte-marrow imaging is tempered by the limitations of in vitro labeling. In vivo labeling has been investigated, and a murine monoclonal antigranulocyte antibody appears promising. Some investigations have focused on fluorodeoxyglucose imaging. Although this method is sensitive, specificity is a concern.
Index Terms: Hip, infection, 442.20 • Hip, prostheses, 442.454 • Hip, radionuclide studies, 442.1217 • Knee, infection, 452.20 • Knee, prostheses, 452.454 • Knee, radionuclide studies, 452.1217
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LEARNING OBJECTIVES FOR TEST 5
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After reading this article and taking the test, the reader will be able to:
- List at least three types of joint replacements.
- Describe the most common complications of joint replacement surgery.
- Discuss interpretation of sequential bone-gallium images and combined leukocyte-marrow images.
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Introduction
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A primordial knee arthroplasty, unearthed by archaeologists studying Egyptian mummies, indicates that the concept of replacing the defective human joint has existed for several thousand years. Although attempts at joint replacement surgery were sporadically carried out in the 19th century, the era of modern arthroplasty, which has revolutionized the treatment of patients with advanced disorders of the hip and knee, began in earnest in the second half of the 20th century (1).
Sir John Charnley, often referred to as the father of the total hip replacement, developed the predecessors of today’s hip replacements during the late 1950s and early 1960s. Modern-day hip prostheses, known as modular because the surgeon can modify the different components to suit an individual patient’s needs, are made of metal (cobalt, chromium, and titanium) and plastic (ultrahigh-molecular-weight polyethylene) (Fig 1a, 1b) (2,3). These components can be attached to the native bone in a variety of ways. In the case of cemented devices, surgical cement (polymethylmethacrylate) secures the hardware. Fixation of the cementless, porous-coated prosthesis is accomplished by means of bony ingrowth, which interdigitates into a porous coating applied to the surface of the device (Fig 1c). In yet another type, bonding is accomplished by application of a hydroxyapatite compound to the surface of the components, which stimulates new bone formation and serves as an attachment for newly formed osseous tissue around the hardware. Acetabular components can also be forced, or press-fit, into the acetabulum and, if needed, can be further secured with orthopedic screws (2).
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Figure 1a. (a) Photograph shows an early Charnley femoral component (left) and a modular femoral component (right). In the modular type, the head and stem are separate units that can be customized for the individual patient. (b) Photograph shows a porous-coated acetabular component (left) and an ultrahigh-molecular-weight polyethylene acetabular liner (right). The holes in the acetabular component permit fixation with screws when needed. (c) Photograph shows a porous-coated acetabular component (same component as in b). The irregular, or porous, surface allows bony ingrowth.
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Figure 1b. (a) Photograph shows an early Charnley femoral component (left) and a modular femoral component (right). In the modular type, the head and stem are separate units that can be customized for the individual patient. (b) Photograph shows a porous-coated acetabular component (left) and an ultrahigh-molecular-weight polyethylene acetabular liner (right). The holes in the acetabular component permit fixation with screws when needed. (c) Photograph shows a porous-coated acetabular component (same component as in b). The irregular, or porous, surface allows bony ingrowth.
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Figure 1c. (a) Photograph shows an early Charnley femoral component (left) and a modular femoral component (right). In the modular type, the head and stem are separate units that can be customized for the individual patient. (b) Photograph shows a porous-coated acetabular component (left) and an ultrahigh-molecular-weight polyethylene acetabular liner (right). The holes in the acetabular component permit fixation with screws when needed. (c) Photograph shows a porous-coated acetabular component (same component as in b). The irregular, or porous, surface allows bony ingrowth.
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The prototype of the modern knee replacement, known as the total condylar knee replacement, was developed at the Hospital for Special Surgery in New York City in the mid-1970s under the leadership of Dr John N. Insall (1). This fixed-bearing knee implant consisted of a one-piece metallic femoral component, a polyethylene tibial tray with a central peg, and a polyethylene patellar component. The mobile-bearing prosthesis used today (Fig 2) affords improved joint mobility with less polyethylene breakdown than its fixed-bearing predecessor (1,4).
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Figure 2. Photographs show anterior (left) and lateral (right) views of a mobile-bearing total knee prosthesis, which consists of femoral and tibial components and a polyethylene liner.
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In this article, the complications of prosthetic joint surgery are reviewed and the role of radionuclide imaging in diagnosis of the infected joint replacement is discussed.
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Complications of Prosthetic Joint Surgery
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Nearly 500,000 hip and knee arthroplasties are performed annually in the United States. With the increasing longevity of senior citizens coupled with the demands of young, active arthroplasty recipients, it is estimated that this number may exceed 700,000 by the year 2030 (5). Despite its success, joint replacement surgery is not without complications, including aseptic loosening, dislocation, fracture, and infection. Many of these complications can be readily diagnosed and treated (Fig 3). However, differentiating infection from aseptic loosening, the most frequent complication of joint replacement surgery, is more difficult because the clinical presentations of and histopathologic changes in these entities are remarkably similar (3,6).
Aseptic Loosening
By 10 years after implantation, 50% of prostheses demonstrate radiographic evidence of loosening and 30% require revision (7,8). Although prosthesis design and technical factors are responsible in some cases, there is an increasing body of evidence that a significant number of cases of aseptic loosening are the result of an inflammatory-immune reaction (9). Histopathologic examinations of failed prostheses show a synoviumlike pseudomembranous structure that develops at the cement-bone interface. The cellular composition of the pseudomembrane is varied: Histiocytes are seen most frequently (95% of specimens), followed by giant cells (80%) and lymphocytes and plasma cells (25%). Neutrophils are present in less than 10% of cases (10).
It is believed that particulate debris, produced by component fragmentation, attracts and activates tissue phagocytes normally present around the prosthesis. Because this debris is impervious to regular enzymatic destruction, the degradative function of the inflammatory cells is frustrated, leading to repeated but unsuccessful attempts at phagocytosis. These ongoing attempts at phagocytosis stimulate secretion of proinflammatory cytokines and proteolytic enzymes, which damage bone and cartilage and activate immune cells. The heightened inflammatory response leads to osteolysis, which, if allowed to continue, results in loss of supporting osseous tissues and eventually loosening of the prosthesis (9–11).
Infection
The rate of infection following primary implantation is about 1% for hip prostheses and 2% for knee prostheses. The rate of infection following revision surgery is somewhat higher: about 3% for hip replacements and 5% for knee replacements (12). Staphylococcus epidermidis (31% of cases) and S aureus (20%) are the most common offending organisms, whereas Streptococcus viridans (11%), Escherichia coli (11%), Enterococcus faecalis (8%), and group B streptococci (5%) are less frequently encountered (13). About one-third of these infections develop within 3 months, another third develop within 1 year, and the remainder develop more than 1 year after surgery (14). At histopathologic analysis, the inflammatory reaction accompanying the infected prosthesis is identical to that present in aseptic loosening, with one important difference: Neutrophils, usually absent in aseptic loosening, are invariably present in large numbers in infection (13,14).
Treatment and Diagnosis
It is extremely important to be able to differentiate aseptic loosening from infection because the treatment of these entities is radically different. In aseptic loosening, the patient typically undergoes a single-stage revision arthroplasty, which requires only one hospital admission. However, the treatment of infected hardware is more complex and often requires multiple admissions. First, an excisional arthroplasty, or removal of the prosthesis, is performed. This procedure is followed by a protracted course of antimicrobial therapy. Eventually, the patient undergoes a revision arthroplasty (3,13,15).
Therefore, to be useful, a diagnostic test must be specific as well as sensitive. A test that is sensitive but not specific can lead to multiple costly operations in many patients in whom a single intervention may have sufficed. Similarly, the specific but insensitive test will also result in additional surgical intervention because undiagnosed infection will cause any revision implant to fail. Nonspecific markers of inflammation such as the erythrocyte sedimentation rate and C-reactive protein level may be elevated in both loosening and infection. The results of joint aspiration have been disappointing, with large numbers of false-positive and false-negative results having been reported (15–18). Plain radiography is neither sensitive nor specific, and cross-sectional imaging modalities, such as computed tomography and magnetic resonance imaging, are limited by the artifacts caused by the hardware itself. Radionuclide imaging, which reflects physiologic rather than anatomic changes, is not hindered by the presence of metallic hardware and is the current imaging modality of choice for evaluation of suspected joint replacement infection (19,20).
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Radionuclide Imaging
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Bone Scintigraphy
Bone scintigraphy is widely available, easily performed, and exquisitely sensitive. Most investigators would agree that a study with normal results (ie, one in which periprosthetic uptake is indistinguishable from that of surrounding nonarticular bone) is strong evidence against a prosthetic abnormality (Fig 4) (19). However, the significance of increased periprosthetic uptake is less certain. For hip prostheses, diffusely increased periprosthetic uptake is often equated with infection. The accumulation of bone-seeking tracers such as technetium-99m methylene diphosphonate, which localize on the surface of the bone mineral matrix, is dependent on blood flow and especially on the rate of new bone formation (20). Consequently, any cause of accelerated new bone formation may result in increased periprosthetic activity on bone images. The diffuse pattern seen with infection is probably due to generalized osteolysis, which is also present in aseptic loosening secondary to inflammation. Therefore, these two entities may be indistinguishable at scintigraphy (Fig 5) (18).
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Figure 4a. Anterior (left) and posterior (right) bone scintigrams of a right total hip replacement (a) and a left total knee replacement (b) show normal periprosthetic uptake (ie, indistinguishable from that of surrounding nonarticular bone).
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Figure 4b. Anterior (left) and posterior (right) bone scintigrams of a right total hip replacement (a) and a left total knee replacement (b) show normal periprosthetic uptake (ie, indistinguishable from that of surrounding nonarticular bone).
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Figure 5a. Anterior bone scintigrams show diffuse intense uptake around the femoral component of an infected right total hip replacement (a) and a similar uptake pattern around an aseptically loosened right total hip prosthesis (b).
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Figure 5b. Anterior bone scintigrams show diffuse intense uptake around the femoral component of an infected right total hip replacement (a) and a similar uptake pattern around an aseptically loosened right total hip prosthesis (b).
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The introduction of porous-coated prostheses has further complicated analysis of the bone image. For stabilization purposes, these devices were designed to stimulate bony ingrowth; hence, periprosthetic uptake patterns are more variable than those associated with the cemented variety (21). Focal uptake at the distal tip of the femoral component of a cemented device more than 1 year old is often attributed to aseptic loosening (Fig 6). However, in the case of the porous-coated prosthesis, this pattern is often present in asymptomatic individuals for considerably longer after surgery (18–21).
Uptake patterns around knee prostheses are even more variable than those around hip prostheses, with large numbers of asymptomatic patients demonstrating persistent periprosthetic activity for several years after implantation (22,23).
To complicate matters even further, about two-thirds of all joint replacement infections occur during the first year after implantation, when, regardless of the type or location of the prosthesis, periprosthetic uptake is so variable that only a normal bone scan contributes useful information. The overall accuracy of radionuclide bone imaging in evaluation of the prosthetic joint is about 50%–70%. Nevertheless, bone imaging is useful as an initial screening test because it has a high negative predictive value (19).
Sequential Bone-Gallium Imaging
In an effort to improve the specificity of bone scintigraphy, complementary gallium imaging is often performed. Because the mechanisms of uptake of bone-seeking tracers and gallium-67 citrate are different, each study provides complementary information about different aspects of a particular disease process. Over time, a standardized method of interpreting sequential bone-gallium images has evolved (24): (a) The images are negative for infection when the gallium images are normal, regardless of the bone scan findings, or when the spatial distributions of the two tracers are congruent and the intensity of gallium uptake is less than that of the bone tracer (Fig 7). (b) The images are positive for infection when the distributions of the two tracers are spatially incongruent (Fig 8) or when their distributions are spatially congruent and the intensity of gallium uptake exceeds that of the bone agent. (c) The images are equivocal for infection when the distributions of the two tracers are spatially congruent and the intensities of uptake of the tracers are similar (Fig 9).
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Figure 7a. (a) Anterior bone image (left) shows intense uptake around a right total hip replacement, but an anterior gallium image (right) is normal. These results are negative for infection. (b) Anterior bone (left) and gallium (right) images both show increased activity at the tip and greater trochanteric region of a right hip replacement. However, the intensity of gallium activity is considerably less than that of the bone agent. These results are negative for infection.
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Figure 7b. (a) Anterior bone image (left) shows intense uptake around a right total hip replacement, but an anterior gallium image (right) is normal. These results are negative for infection. (b) Anterior bone (left) and gallium (right) images both show increased activity at the tip and greater trochanteric region of a right hip replacement. However, the intensity of gallium activity is considerably less than that of the bone agent. These results are negative for infection.
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Figure 8. Anterior bone (left) and gallium (right) images of an infected left total knee replacement show spatially incongruent distributions of the two tracers. Note the extension of gallium activity inferiorly along the medial aspect of the tibia.
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Figure 9. Anterior bone (left) and gallium (right) images show similar distributions and intensities of activity around a right knee prosthesis. These results are equivocal for infection.
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The uptake of gallium is related to inflammation in general and not to infection specifically. Consequently, with an overall accuracy of about 70%–80%, this technique is not well suited for distinguishing the inflamed, aseptically loosened prosthesis from the infected prosthesis (Fig 10) (18,19).
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Figure 10. Anterior gallium image (right) shows activity in the intertrochanteric region of a right hip replacement, which is spatially incongruent with the distribution of activity on an anterior bone image (left); this result is consistent with infection. At surgery, an aseptically loosened prosthesis was revised. An intense inflammatory reaction was present at histopathologic examination.
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Labeled Leukocyte Scintigraphy
The labeling of inflammatory cells that migrate to sites of infection may represent the single most important achievement in radionuclide diagnosis of infection to date. Uptake of labeled cells is dependent on intact chemotaxis, the number and types of cells labeled, and the principal cellular component of a given inflammatory response. In the typical clinical environment, although a mixed population of leukocytes is labeled, the majority of cells labeled are neutrophils. Hence, the procedure is most useful for detecting neutrophil-mediated inflammatory processes. At least in theory, labeled leukocyte imaging is thus particularly well suited for distinguishing between the inflamed aseptically loosened prosthesis, in which neutrophils are generally absent, and the infected prosthesis, in which neutrophils are present (Fig 11). Yet, the results of early studies varied widely as to the accuracy of this technique for diagnosing the infected prosthesis (6,18). Low sensitivity was attributed to the "chronicity" of the process, whereas low specificity was attributed to "inflammation." However, the paucity of neutrophils in the aseptically loosened prosthesis and the invariable presence of these cells in the setting of infected hardware would suggest that there is another explanation for the inconsistent results.
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Figure 11a. (a) Anterior (left) and posterior (right) labeled leukocyte images show intense accumulation around an infected right total hip replacement, which was removed at surgery. (b) Anterior (left) and posterior (right) labeled leukocyte images of an aseptically loosened right hip replacement show a normal appearance.
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Figure 11b. (a) Anterior (left) and posterior (right) labeled leukocyte images show intense accumulation around an infected right total hip replacement, which was removed at surgery. (b) Anterior (left) and posterior (right) labeled leukocyte images of an aseptically loosened right hip replacement show a normal appearance.
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Interpretation of labeled leukocyte images, like interpretation of most other images, entails a comparison of activity in the region of interest to activity in some predefined normal reference point. In the case of prostheses, periprosthetic activity is often compared with adjacent bone activity or with activity in the corresponding contralateral extremity. Increased periprosthetic activity compared with that of the reference point is generally interpreted as positive for infection (Fig 12). However, labeled leukocytes accumulate not only in infection but in the bone marrow as well (6). Historically, hematopoietically active marrow in adults has been assumed to be limited to the axial skeleton and proximal appendicular skeleton, with any labeled leukocyte activity outside this distribution ascribed to infection. In fact, the distribution of hematopoietically active marrow is extremely variable and can be affected by a variety of entities, including tumors, fractures, hemolytic anemias, and even orthopedic hardware (19,25, 26). Clearly, the explanation for the inconsistent results reported for labeled leukocyte imaging is thus neither chronicity nor nonspecific inflammation, but rather an inability to distinguish uptake of labeled leukocytes in infection from uptake in aberrantly located but otherwise normal marrow.
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Figure 12a. (a) Posterior labeled leukocyte image shows minimal periprosthetic activity in the intertrochanteric region of a left total hip replacement (arrow). The intensity of this uptake, which is less than that of the adjacent pelvis, is equal to that of the corresponding contralateral region. Consequently, this image would be interpreted as negative for infection. (b) Anterior labeled leukocyte image shows intense uptake around a left total knee prosthesis and is positive for infection.
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Figure 12b. (a) Posterior labeled leukocyte image shows minimal periprosthetic activity in the intertrochanteric region of a left total hip replacement (arrow). The intensity of this uptake, which is less than that of the adjacent pelvis, is equal to that of the corresponding contralateral region. Consequently, this image would be interpreted as negative for infection. (b) Anterior labeled leukocyte image shows intense uptake around a left total knee prosthesis and is positive for infection.
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This problem has been overcome by the addition of complementary bone marrow imaging, which is usually performed with Tc-99m sulfur colloid. Both labeled leukocytes and sulfur colloid accumulate in the bone marrow, but only labeled leukocytes accumulate in infection. Thus, at combined labeled leukocyte–marrow imaging, when the distributions of the two tracers are similar or spatially congruent, the labeled leukocyte activity is due to the presence of marrow. When there is activity on the labeled leukocyte images without corresponding activity on the sulfur colloid images, the labeled leukocyte uptake is due to infection (Fig 13). In contrast to the results reported for labeled leukocyte imaging alone, the results of combined leukocyte-marrow imaging of prosthetic joints have been uniformly excellent, with an accuracy of 90% or greater (25,26).
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Figure 13a. (a) Posterior labeled leukocyte (left) and marrow (right) images show no marrow uptake that corresponds to labeled leukocyte activity in the lateral aspect of a left hip replacement (same patient as in Fig 12a). The surgical specimen showed growth of Propionibacterium acnes. (b) Anterior labeled leukocyte (left) and marrow (right) images show that the distribution of marrow uptake is virtually identical to that of labeled leukocyte activity in an aseptically loosened left knee prosthesis (same patient as in Fig 12b). In both cases, the addition of marrow imaging allowed the correct diagnosis to be made. These cases illustrate an important fact: In leukocyte imaging, it is neither the presence nor the intensity of labeled leukocyte activity but rather the relationship of such uptake to marrow activity that is important.
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Figure 13b. (a) Posterior labeled leukocyte (left) and marrow (right) images show no marrow uptake that corresponds to labeled leukocyte activity in the lateral aspect of a left hip replacement (same patient as in Fig 12a). The surgical specimen showed growth of Propionibacterium acnes. (b) Anterior labeled leukocyte (left) and marrow (right) images show that the distribution of marrow uptake is virtually identical to that of labeled leukocyte activity in an aseptically loosened left knee prosthesis (same patient as in Fig 12b). In both cases, the addition of marrow imaging allowed the correct diagnosis to be made. These cases illustrate an important fact: In leukocyte imaging, it is neither the presence nor the intensity of labeled leukocyte activity but rather the relationship of such uptake to marrow activity that is important.
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Imaging with Investigational Agents
Although extremely accurate, leukocyte-marrow scintigraphy is hampered by significant limitations. The in vitro labeling process is labor intensive, is not always available, and requires direct contact with blood products. The need for marrow imaging adds to the complexity and cost of the study and is an additional inconvenience to patients, many of whom are elderly and debilitated. In an effort to maintain the accuracy of the study while reducing or eliminating the disadvantages, several methods of labeling leukocytes in vivo have been investigated, including use ofpeptides and antigranulocyte antibodies or antibody fragments. The only such agent currently under active investigation in the United States is a Tc-99m–labeled murine monoclonal antibody of the immunoglobulin M class, which binds with a very high affinity to CD-15 receptors present on the surface membrane of human polymorphonuclear leukocytes. Accumulation of this agent at sites of infection is probably due to binding of the antibody to circulating neutrophils, which subsequently migrate to the nidus of infection, as well as to diffusion of the antibody across capillary membranes with subsequent binding to neutrophils already sequestered in a focus of infection. Preliminary data suggest that this agent may be a suitable alternative to in vitro labeled leukocytes, although optimal imaging times and the need for complementary marrow imaging have yet to be determined (Fig 14) (27).
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Figure 14. Anterior 60-minute labeled antibody image (left) shows intense activity around an infected right knee prosthesis. Anterior labeled leukocyte (middle) and marrow (right) images also show infection.
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There are data that suggest that fluorodeoxyglucose (FDG) is useful for detecting musculoskeletal infection (28). FDG, a deoxyglucose labeled with fluorine-18, is taken up by cells like glucose but, unlike glucose, is not metabolized. Any process that involves increased cellular respiration, as seen in infection, inflammation, reparative state, or tumors, is expected to show increased activity at FDG positron emission tomography. One group of investigators recently reported that although the technique is very accurate for detection of infected hip prostheses, false-positive results were encountered in evaluation of knee prostheses (29). We have found that, although FDG imaging is exquisitely sensitive, the technique does not appear to allow differentiation between the inflamed aseptically loosened prosthesis and the infected one, regardless of the location (Fig 15) (30). This result is not surprisingwhen one considers that FDG uptake is dependent on tissue metabolism. Inflammation and infection are both hypermetabolic states and will therefore manifest as areas of increased activity. In our population, leukocyte-marrow imaging was superior to FDG imaging, which performed no better than bone-gallium imaging.
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Figure 15a. (a) Anterior FDG image (left) shows intense activity around an infected left total knee replacement. Anterior labeled leukocyte (middle) and marrow (right) images also show infection. (b) Anterior FDG image (left) also shows intense activity around a left total knee replacement, which is compatible with infection. Anterior labeled leukocyte (middle) and marrow (right) images do not show infection. An aseptically loosened prosthesis was revised at surgery. Intense inflammatory changes were present.
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Figure 15b. (a) Anterior FDG image (left) shows intense activity around an infected left total knee replacement. Anterior labeled leukocyte (middle) and marrow (right) images also show infection. (b) Anterior FDG image (left) also shows intense activity around a left total knee replacement, which is compatible with infection. Anterior labeled leukocyte (middle) and marrow (right) images do not show infection. An aseptically loosened prosthesis was revised at surgery. Intense inflammatory changes were present.
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Conclusions
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Although many of the complications of joint replacement surgery can be easily diagnosed and treated, differentiating aseptic loosening from infection remains a daunting task. The relationship between aseptic loosening and inflammation makes nonspecific indicators of inflammation of limited usefulness. Radionuclide bone imaging is best used as a screening procedure. Although negative study results effectively exclude a prosthetic complication, positive study results require further investigation. Periprosthetic activity can be identified in asymptomatic individuals with porous-coated hip replacements as well as in most patients with knee replacements for a period of well over 1 year. Therefore, the mere presence of periprosthetic activity, regardless of the location, type, and age of the device, cannot be automatically equated with an abnormality. Further complicating matters is the fact that about two-thirds of all prosthetic infections occur during the first year after implantation, when periprosthetic uptake can be a normal finding, regardless of the type or location of the prosthesis.
Despite its not insignificant limitations, combined leukocyte-marrow scintigraphy remains the procedure of choice for diagnosis of the infected joint replacement. To be successful, future investigations will need to continue to focus on methods of labeling neutrophils in vivo or perhaps focus on developing bacteria-specific tracers.
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Footnotes
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Abbreviation: FDG = fluorodeoxyglucose
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