https://doi.org/
Journal of Perioperative Practice
2022, Vol. 32(1-2) 15 –21
© The Author(s) 2020
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DOI: 10.1177/1750458920961347
journals.sagepub.com/home/ppj
The Association for Perioperative PracticeReview
Radiological evaluation of postoperative
osteomyelitis in long bones: Which is
the best tool?
Andrew Kailin Zhou1,2 , Milind Girish1,2 , Azeem Thahir1,
Jiang An Lim1,2 , Xiaoyu Chen1,2 and Matija Krkovic1
Abstract
Currently, definitive diagnosis of osteomyelitis involves a combination of clinical signs, symptoms, laboratory tests,
imaging modalities and cultures from blood, joint or body fluid. Imaging plays a critical role in the osteomyelitis diagnosis.
Each of these tests incurs an additional cost to the patient or healthcare system and their use varies according to the
preference of the healthcare professional and the healthcare setup. Imaging plays a critical role in the diagnosis and
management of postoperative long bone osteomyelitis, with the aim of reducing long-term complications such as non-
union, amputation and pathological fractures. In this review, we discuss the key findings on different radiological
modalities and correlate them with disease pathophysiology. Currently, magnetic resonance imaging is the best available
imaging modality due to its sensitivity in detecting early signs of long bone osteomyelitis and high soft tissue resolution.
Other modalities such as radio-nuclear medicine, computed tomography and ultrasound have been proved to be useful
in different clinical scenarios as described in this narrative review.
Keywords
Postoperative osteomyelitis / Radiological evaluation / Long bone infection / Diagnostic tools / Health economics
Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication 3 Sep 2020.
Introduction
With the increase in the number of traumatic accidents
and orthopaedic surgeries performed, it is not surprising
that there is a rise in the incidence of long bone
infection (Calhoun et al 2009). The annual incidence of
long bone osteomyelitis was 5.45 cases per 100,000
person years, age and sex-adjusted, between 1969 and
2009 (Kremers et al 2015). In elective trauma
surgeries, treatment refractory acute osteomyelitis
occurred 1–5% after a closed fracture and 3–50% after
an open fracture, depending on the severity (Walter et al
2012). Most healthcare professionals find bone
infection intimidating to treat, particularly in the
postoperative setting when involving non-united
fractures or metal work in situ. There are numerous
complications which arise due to osteomyelitis of long
bones such as non-union, amputation, pathological
fracture and further spread of infection (McKee et al
2010, McNally et al 2016). Diagnosing osteomyelitis is
multifaceted, where a combination of clinical
examination and diagnostic assessment is required for a
diagnosis. A reasonable diagnosis of osteomyelitis can
made if at least one of the four clinical signs are present
(fever >38C and local inflammation, suspicion of
osteoarticular infection, reduction in mobility and joint
swelling) and one of the four investigations are positive
(blood culture, purulent joint fluid, culture from joint
aspiration and imaging consistent with bone or joint
infection) (Mitha et al 2012). Imaging plays a critical role
in the diagnosis of osteomyelitis but incurs an additional
cost to the patient or healthcare system and their use
varies according to local/professional preference (Lee et
al 2016). Some imaging modalities are not completely
risk free, involving high doses of radiation and allergenic
contrasts (Lin 2010). In this narrative review, we have
summarised the important radiological tools which may
best evaluate postoperative infection in long bones
(Figure 1).
1Department of Trauma and Orthopaedics, Addenbrookes Major Trauma
Unit, Cambridge University Hospitals, Cambridge, UK
2School of Clinical Medicine, University of Cambridge, Cambridge, UK
Corresponding author:
Andrew Kailin Zhou, School of Clinical Medicine, University of
Cambridge, Cambridge CB2 0SP, UK.
Email: azhou1998@icloud.com
be
16 Journal of Perioperative Practice 32(1-2)
Plain radiographs
Plain radiographs should be the initial imaging for
suspected postoperative long bone osteomyelitis (Lee
et al 2016) as they may exclude differentials such as
fractures or bone tumours. Plain radiographs can be
used to look for evidence of osteomyelitis including
osteopenia, bone destruction and cortical breaches
followed by periosteal reactions (Lee et al 2016).
However, 80% of patients who present in the first two
weeks of infection will have a relatively normal
radiograph (Jaramillo 2011). In chronic osteomyelitis, a
focal sclerotic lesion with a lucent rim, sequestrum, is
visible on plain radiographs (Lee et al 2016), potentially
followed by an involucrum (Pineda et al 2009). These
abnormalities are not specific to long bone osteomyelitis
and can be found in stress fracture, bone tumours and
soft tissue infections (Lee et al 2016). Metalwork in situ
makes plain radiographs less useful for the differential
diagnosis of osteomyelitis, although the state of the
metalwork can be assessed. Despite the lack of
specificity, plain radiographs rule out other diagnoses
and are therefore the primary initial imaging modality for
postoperative long bone infections.
Ultrasound scans
Ultrasound scans (USS) are useful to diagnose acute
osteomyelitis, identifying associated subperiosteal
collections and adjacent joint effusions or an unspecific
fluid collection in soft tissue suggesting an abscess (Lee
et al 2016). In a colour doppler, soft tissue oedema is
seen in areas around the affected bone (Jaramillo
2011). Another common use is guiding aspiration or
needle biopsy for microbiological diagnosis (Lee et al
2016). Furthermore, USS are low cost, at £39 to
operate, rapidly completed and highly accessible without
known side effects (NHS Improvement n.d.). Although
USS are limited in diagnosing osteomyelitis itself, they
may identify secondary signs of osteomyelitis and guide
aspirations/biopsies (Lee et al 2016).
Computed tomography
Computed tomography (CT) tends to have a limited role
in assessment of postoperative long bone osteomyelitis.
CT more reliably identifies cortical destruction, periosteal
reactions and sequestrum formation, which appears as
sclerotic lesions with a lucent rim. CT also identifies
blurring of fat planes, increased density of
subcutaneous fat and swelling of affected muscles
which indicate soft tissue infection surrounding the
postoperative long bone osteomyelitis (Palestro et al
2007). It has a higher resolution compared to magnetic
resonance imaging (MRI) in imaging the osseous
changes from the osteomyelitis and therefore is useful
to assess postoperative bone stock in the healing phase.
Similarly, to US, CT can also detect periosteal abscesses.
CT therefore plays a similar role to US in the diagnosis of
osteomyelitis as well as guiding aspirations and
biopsies, particularly for deeply seated abscesses in
obscure locations (Lee et al 2016) where its high
resolution allows differentiation between areas of
infection and soft tissue structures such as major blood
vessels and nerves (Lee et al 2016).
Figure 1 A flowchart guiding the choice of imaging in long bone osteomyelitis
Intravenous contrasts significantly enhance CT
capabilities of distinguishing in-between different
tissues. For example, the centre of an abscess will not
enhance with contrast due to insufficient blood supply.
However, a demarcating increased brightness around
the wall will be noted due to hyperaemia and increased
capillary permeability within the abscess wall (Palestro
et al 2007).
Although signs of long bone osteomyelitis can be
detected, CT has a much lower resolution in comparison
to MRI for soft tissues. CT is not able to detect bone
marrow oedema, hence is not suitable in the detection
of early postoperative long bone osteomyelitis (Lee et al
2016). Furthermore, the CT image is degraded by streak
artefacts when metalwork is present (Pineda et al
2009); however, metal artefact reduction applications in
CT are making the metal impact on imaging quality less
significant. Overall, CT is a cheaper alternative for
patients with contraindications to MRI, costing £69 per
scan (NHS Improvement n.d.), and can be used in
surgical planning of treatments of osteomyelitis.
However, it has a very limited role in initial diagnosis of
osteomyelitis.
Magnetic resonance imaging
(MRI) is known as the gold standard imaging modality
for osteomyelitis, providing good cross-sectional views of
the bone and surrounding soft tissue (Jaramillo 2011).
MRI can identify osteomyelitis as early as one to two
days after onset of infection (Jaramillo 2011). Normal
bone cortex exhibits low-signal intensities and bone
marrow has a higher T1 signal intensity (T1 images
highlight fat tissues within the body, whilst T2 images
highlight fat and water within the body) (Palestro et al
2007). The earliest sign of osteomyelitis on an MRI is
bone marrow oedema which presents as a higher signal
intensity in the medullary cavity in comparison to
adjacent or contralateral healthy bones (Pugmire et al
2014).
Other common signs picked up by MRI include
intraosseous, subperiosteal abscesses, phlegmon, sinus
tracts and periostitis (Donovan & Schweitzer 2010, Lee
et al 2016). Intraosseous and subperiosteal abscess will
have low signal T1 intensities with a thin rim of
intermediate intensity around the abscess after
intravenous contrast administration, which is indicative
of hypervascular granulation tissue (Lee et al 2016).
Furthermore, if there is an intramedullary abscess, it
presents very similarly to bone marrow as they both have
higher signal intensity in the medullary cavity. A
phlegmon is a solid inflammatory mass and can be
differentiated from abscesses through increased
enhancement variability across the mass and a negative
penumbra sign (Lee et al 2016). This distinction has
significance as abscesses require urgent intervention
through aspiration or decompression (Collins et al
2005). Sinus tracts, another complication of
osteomyelitis, are fluid filled extensions from the bone to
the skin surface and are commonly identified through
increased peripheral enhancement after intravenous
contrast (Lee et al 2016). Periostitis is observed through
low-signal periosteum elevated away from the bone,
correlating to the periosteal reaction observed on plain
radiographs (Lee et al 2016).
Intravenous contrast agents are administered to
increase the enhancement of inflammation due to
increased hyperaemia and capillary permeability. T1-
weighted images can be used to detect these images
because of the short T1 relaxation time of paramagnetic
contrasts such as gadolinium-containing compounds
(Palestro et al 2007). In uncomplicated cases,
gadolinium is not required as the fat-suppressed T2
imaging obtains the same signal abnormalities as post-
contrast T1 (Miller et al 1997). Studies have shown,
gadolinium should be reserved for refractory cases due
to abscess formation and suspected infection revolving
around a joint (Miller et al 1997).
Unfortunately, MRI is not useful in identifying sequestra
because they appear black just like normal cortical
bone. Thus, they are inferior to CT when observing
osseous changes of osteomyelitis. Although MRI is a
sensitive test for detecting long bone osteomyelitis, it
tends to overestimate the extent of infection in the acute
phase when bone oedema is presented with a high-
signal intensity in the medullary canal (Pugmire et al
2014). The specificity of MRI is much less than the
sensitivity, due to the pathology of osteomyelitis
overlapping with malignancies and trauma (Lee et al
2016, Pugmire et al 2014). Thus, the interpretation of
MRI scan in osteomyelitis will be challenging and
requires a radiologist with a specialist interest in
musculoskeletal imaging. Furthermore, MRI imaging in
postoperative patients is easily misinterpreted because
postoperative changes can persist for months or years
and can be misinterpreted for infection. Hence, MRI
findings should always be correlated to the clinical
history and examination to prevent unnecessary further
investigations and treatments.
Similar to CT, MRI imaging also will be degraded by
metallic implants due to the presence of metallic
artefacts (Vaz et al 2017).
There are other factors which limit the usefulness of MRI
such as permanent pacemakers and younger patients
requiring sedation or general anaesthesia in order to
undergo the scan. Also, each MRI scan costs
approximately £130 and there is still a lack of
accessibility in various regions (Lee et al 2016, NHS
Improvement n.d.). Unfortunately, the presence of
metalwork is common in postoperative long bone
infection thus reducing the usefulness of MRI in the
diagnosis of postoperative long bone infections, thus it
Zhou et al. 17
Plain radiographs
Plain radiographs should be the initial imaging for
suspected postoperative long bone osteomyelitis (Lee
et al 2016) as they may exclude differentials such as
fractures or bone tumours. Plain radiographs can be
used to look for evidence of osteomyelitis including
osteopenia, bone destruction and cortical breaches
followed by periosteal reactions (Lee et al 2016).
However, 80% of patients who present in the first two
weeks of infection will have a relatively normal
radiograph (Jaramillo 2011). In chronic osteomyelitis, a
focal sclerotic lesion with a lucent rim, sequestrum, is
visible on plain radiographs (Lee et al 2016), potentially
followed by an involucrum (Pineda et al 2009). These
abnormalities are not specific to long bone osteomyelitis
and can be found in stress fracture, bone tumours and
soft tissue infections (Lee et al 2016). Metalwork in situ
makes plain radiographs less useful for the differential
diagnosis of osteomyelitis, although the state of the
metalwork can be assessed. Despite the lack of
specificity, plain radiographs rule out other diagnoses
and are therefore the primary initial imaging modality for
postoperative long bone infections.
Ultrasound scans
Ultrasound scans (USS) are useful to diagnose acute
osteomyelitis, identifying associated subperiosteal
collections and adjacent joint effusions or an unspecific
fluid collection in soft tissue suggesting an abscess (Lee
et al 2016). In a colour doppler, soft tissue oedema is
seen in areas around the affected bone (Jaramillo
2011). Another common use is guiding aspiration or
needle biopsy for microbiological diagnosis (Lee et al
2016). Furthermore, USS are low cost, at £39 to
operate, rapidly completed and highly accessible without
known side effects (NHS Improvement n.d.). Although
USS are limited in diagnosing osteomyelitis itself, they
may identify secondary signs of osteomyelitis and guide
aspirations/biopsies (Lee et al 2016).
Computed tomography
Computed tomography (CT) tends to have a limited role
in assessment of postoperative long bone osteomyelitis.
CT more reliably identifies cortical destruction, periosteal
reactions and sequestrum formation, which appears as
sclerotic lesions with a lucent rim. CT also identifies
blurring of fat planes, increased density of
subcutaneous fat and swelling of affected muscles
which indicate soft tissue infection surrounding the
postoperative long bone osteomyelitis (Palestro et al
2007). It has a higher resolution compared to magnetic
resonance imaging (MRI) in imaging the osseous
changes from the osteomyelitis and therefore is useful
to assess postoperative bone stock in the healing phase.
Similarly, to US, CT can also detect periosteal abscesses.
CT therefore plays a similar role to US in the diagnosis of
osteomyelitis as well as guiding aspirations and
biopsies, particularly for deeply seated abscesses in
obscure locations (Lee et al 2016) where its high
resolution allows differentiation between areas of
infection and soft tissue structures such as major blood
vessels and nerves (Lee et al 2016).
Figure 1 A flowchart guiding the choice of imaging in long bone osteomyelitis
Intravenous contrasts significantly enhance CT
capabilities of distinguishing in-between different
tissues. For example, the centre of an abscess will not
enhance with contrast due to insufficient blood supply.
However, a demarcating increased brightness around
the wall will be noted due to hyperaemia and increased
capillary permeability within the abscess wall (Palestro
et al 2007).
Although signs of long bone osteomyelitis can be
detected, CT has a much lower resolution in comparison
to MRI for soft tissues. CT is not able to detect bone
marrow oedema, hence is not suitable in the detection
of early postoperative long bone osteomyelitis (Lee et al
2016). Furthermore, the CT image is degraded by streak
artefacts when metalwork is present (Pineda et al
2009); however, metal artefact reduction applications in
CT are making the metal impact on imaging quality less
significant. Overall, CT is a cheaper alternative for
patients with contraindications to MRI, costing £69 per
scan (NHS Improvement n.d.), and can be used in
surgical planning of treatments of osteomyelitis.
However, it has a very limited role in initial diagnosis of
osteomyelitis.
Magnetic resonance imaging
(MRI) is known as the gold standard imaging modality
for osteomyelitis, providing good cross-sectional views of
the bone and surrounding soft tissue (Jaramillo 2011).
MRI can identify osteomyelitis as early as one to two
days after onset of infection (Jaramillo 2011). Normal
bone cortex exhibits low-signal intensities and bone
marrow has a higher T1 signal intensity (T1 images
highlight fat tissues within the body, whilst T2 images
highlight fat and water within the body) (Palestro et al
2007). The earliest sign of osteomyelitis on an MRI is
bone marrow oedema which presents as a higher signal
intensity in the medullary cavity in comparison to
adjacent or contralateral healthy bones (Pugmire et al
2014).
Other common signs picked up by MRI include
intraosseous, subperiosteal abscesses, phlegmon, sinus
tracts and periostitis (Donovan & Schweitzer 2010, Lee
et al 2016). Intraosseous and subperiosteal abscess will
have low signal T1 intensities with a thin rim of
intermediate intensity around the abscess after
intravenous contrast administration, which is indicative
of hypervascular granulation tissue (Lee et al 2016).
Furthermore, if there is an intramedullary abscess, it
presents very similarly to bone marrow as they both have
higher signal intensity in the medullary cavity. A
phlegmon is a solid inflammatory mass and can be
differentiated from abscesses through increased
enhancement variability across the mass and a negative
penumbra sign (Lee et al 2016). This distinction has
significance as abscesses require urgent intervention
through aspiration or decompression (Collins et al
2005). Sinus tracts, another complication of
osteomyelitis, are fluid filled extensions from the bone to
the skin surface and are commonly identified through
increased peripheral enhancement after intravenous
contrast (Lee et al 2016). Periostitis is observed through
low-signal periosteum elevated away from the bone,
correlating to the periosteal reaction observed on plain
radiographs (Lee et al 2016).
Intravenous contrast agents are administered to
increase the enhancement of inflammation due to
increased hyperaemia and capillary permeability. T1-
weighted images can be used to detect these images
because of the short T1 relaxation time of paramagnetic
contrasts such as gadolinium-containing compounds
(Palestro et al 2007). In uncomplicated cases,
gadolinium is not required as the fat-suppressed T2
imaging obtains the same signal abnormalities as post-
contrast T1 (Miller et al 1997). Studies have shown,
gadolinium should be reserved for refractory cases due
to abscess formation and suspected infection revolving
around a joint (Miller et al 1997).
Unfortunately, MRI is not useful in identifying sequestra
because they appear black just like normal cortical
bone. Thus, they are inferior to CT when observing
osseous changes of osteomyelitis. Although MRI is a
sensitive test for detecting long bone osteomyelitis, it
tends to overestimate the extent of infection in the acute
phase when bone oedema is presented with a high-
signal intensity in the medullary canal (Pugmire et al
2014). The specificity of MRI is much less than the
sensitivity, due to the pathology of osteomyelitis
overlapping with malignancies and trauma (Lee et al
2016, Pugmire et al 2014). Thus, the interpretation of
MRI scan in osteomyelitis will be challenging and
requires a radiologist with a specialist interest in
musculoskeletal imaging. Furthermore, MRI imaging in
postoperative patients is easily misinterpreted because
postoperative changes can persist for months or years
and can be misinterpreted for infection. Hence, MRI
findings should always be correlated to the clinical
history and examination to prevent unnecessary further
investigations and treatments.
Similar to CT, MRI imaging also will be degraded by
metallic implants due to the presence of metallic
artefacts (Vaz et al 2017).
There are other factors which limit the usefulness of MRI
such as permanent pacemakers and younger patients
requiring sedation or general anaesthesia in order to
undergo the scan. Also, each MRI scan costs
approximately £130 and there is still a lack of
accessibility in various regions (Lee et al 2016, NHS
Improvement n.d.). Unfortunately, the presence of
metalwork is common in postoperative long bone
infection thus reducing the usefulness of MRI in the
diagnosis of postoperative long bone infections, thus it
18 Journal of Perioperative Practice 32(1-2)
is pertinent to understand other modalities of imaging
which are not limited by metal artefacts such as nuclear
imaging (Vaz et al 2017).
However, we are now able to use metal artefact
reduction sequence (MARS) MRIs which can minimise
the impact from metalwork. MARS consists of a variety
of techniques to reduce metal artefacts on MRI and can
be categorised into in-plane artefact reduction and
through-plane artefact reduction. In-plane artefact
reduction aims to reduce the effects of artefact in the
image plane through simple modifications of the scan
protocol such as 1.5 T magnet strength rather than 3 T,
increasing bandwidth during slice selection, maintaining
a good signal to noise ratio through increasing the
number of excitations (Hargreaves et al 2011). Through-
plane reduction involves reducing the effects of metal
artefacts in an adjacent plane. The MAVRIC-SL, a
combination of multiacquisition variable-resonance
image combination technique (MARVIC) and slice-
encoding for metal artefact correction (SEMAC), is used
for through-plane artefact reduction (Choi et al 2014).
Overall, MRI is the most useful diagnostic modality due
to its sensitivity in detecting early signs of long bone
osteomyelitis and high soft tissue resolution.
Triple-phase bone scan
Technetium-99m-labelled MDP (Tc99m-MDP) is
administered intravenously, and a three-phase image is
acquired consisting of the flow/perfusion, static tissue
and osseous phases (Palestro et al 2007). A positive
osteomyelitis sign involves presence of increased focal
perfusion, hyperaemia and bone activity (Schauwecker
1992). Because Tc99m-MDP uptake is dependent on
perfusion and bone formation (Galasko 1975), in
osteomyelitis, increased uptake correlates to increased
perfusion and invasion of microorganisms/leukocytes
which form the inflammatory reaction, consequentially
resulting in bone destruction (Mader et al n.d.). Although
triple phase bone scans are easily performed and
sensitive for postoperative long bone osteomyelitis, the
positive signs are not unique to long bone osteomyelitis
(Vaz et al 2017). Hyperperfusion, hyperaemia and
increased bone formation are all characteristic of bony
malignancies, trauma, aspect inflammation, heterotopic
ossification and any other cause of accelerated new
bone formation (Vaz et al 2017). Furthermore, Triple
phase bone scans are the most expensive scans costing
£198 per scan (NHS Improvement n.d.). Additionally,
triple-phase scans are difficult to interpret and can be
ambiguous, thus further imaging may be necessary to
obtain a definitive answer.
Gallium scintigraphy
Gallium scans can be used in conjunction with a triple-
phase bone scan to detect postoperative long bone
infection. Studies have demonstrated that triple-phase
bone scan accuracy ranged from 50 to 70% in infected
long bones, whilst Gallium used in conjunction with
triple-phase bone scans only marginally increased the
accuracy to 65–80% (Love et al 2009). The majority of
the circulating gallium is bound to transferrin, thus
increased blood perfusion results in increased gallium
at the inflammation site (Palestro et al 2007). Bacteria
uptake the gallium directly and through siderophores
(Palestro et al 2007). The gallium is seen on leukocytes
through phagocytosis of bacteria from macrophages and
gallium directly binding to the leukocytes (Palestro et al
2007). Gallium scintigraphy is useful in patients with a
low white cell count as it can detect osteomyelitis in
immunocompromised patients (Palestro 1994). The
current literature suggests that gallium scintigraphy may
be more useful in spinal osteomyelitis and may not be
indicated in postoperative long bone infections (Love et
al 2009, Termaat et al 2005). Limitations of gallium
scintigraphy include the large radiation exposure and
requirement of multiple imaging sessions, potentially
taking up to 48–72 h (Christian et al 2007). Similar to
triple-phase bone scans, uptake is dependent on
inflammation which is not exclusive to long bone
osteomyelitis.
Radio-labelled leukocytes (RLL)
RLL is an in vitro labelling technique utilising 111In-
oxine and 99mTc-exametazime to label the patient’s
leukocytes, most commonly neutrophils (Palestro et al
2007). RLL measures radiotracer accumulation in the
reticuloendothelial system. In order to differentiate
between bone marrow and leukocytes, the white cell
scan is combined with Tc99m-labelled colloid scan,
which maps out the bone marrow (Lee et al 2016). Any
disparity between the white cell scan and the bone
marrow scan is indicative of infection. RLL scans
combined with bone marrow scans are the most
effective in detecting infection in long bones with an
accuracy of approximately 90% across various studies
(Magnuson et al 1988, Pring et al 1986, Rand & Brown
1990). However, as the RLL are most commonly
neutrophils, the infections diagnosed may be limited to
bacterial. For opportunistic infection such as
mycobacterium or yeast, RLL may not be sensitive
enough; therefore, gallium scintigraphy may be preferred
in this scenario. A minimum total white count of
2000mL1 is necessary to achieve adequate
sensitivity (Palestro et al 2007). Furthermore, there have
been reports of two fatalities from cardiopulmonary
failure shortly after administration of the RLL; however,
the precise reasoning behind the fatalities is yet to be
clarified (Magnuson et al 1988). Another drawback
associated with the RLL scan is that it requires skilled
personnel to perform the procedure and it is not readily
available. Although RLL scans have the highest
accuracy, it seems that there are quite a few limitations
which have yet to be resolved.
Positron emission tomography (PET)
Fluorine-18-fluorodeoxyglucose positron emission
tomography (FDG-PET) is used to localise inflammation.
In inflammation and infection, FDG uptake is thought to
be raised due to a combination of increased expression
of glucose transporters on activated inflammatory cells
and a cytokine-mediated increase in affinity for
deoxyglucose from glucose transporters (Mochizuki et al
2001, Paik et al 2004). Although malignancies and
infection present similarly on FDG-PET, it is particularly
useful in localising the abnormality when it is difficult to
determine on other imaging such as MRI (Wang et al
2011). Indeed, Van Vielt et al demonstrated that FDG-
PET is a promising tool in discriminating between
aseptic and septic delayed union in the lower extremities
(van Vliet et al 2018). Furthermore, FDG-PET was proven
to be useful in postoperative patients in distinguishing
postoperative infection from postoperative bone healing
(Koort et al 2004), whilst Lankinen et al showed that
FDG may be effective in confirming low-grade bone
infections in culture negative patients (Lankinen et al
2017). Overall, FDG-PET proves to be a promising
prospect in the diagnosis of long bone infections in
postoperative patients.
SPECT-CT
SPECT-CT is useful in imaging osteomyelitis through
combining anatomical and functional aspects which
allows for more precise localisation of infection foci
(Thang et al 2014). In some cases of bone infection with
adjacent soft tissue involvement, planar images are not
able to distinguish soft tissue from bone infection and
SPECT-CT is able to more precisely define the extent of
infection. A study by Filippi and Schillaci found that
SPECT-CT correctly characterised and localised site
uptake in all suspected osteomyelitis patients and
discriminated between adjacent soft tissue involvement
and bone involvement (Filippi & Schillaci 2006). SPECT-
CT was particularly useful in patients with structural
bone abnormalities after traumatic injury (Filippi &
Schillaci 2006). After trauma, the structural
abnormalities persist and this makes it difficult for CT or
plain radiograph to detect infection because
morphological imaging may not detect infection in
structurally abnormal bone (Seabold et al 1989, Tumeh
et al 1987). Holger et al found that SPECT-CT has
improved specificity in comparison to SPECT alone when
diagnosis chronic osteomyelitis (89% vs. 78%,
respectively) (Horger et al 2003). Van den Wyngaert et al
found that SPECT-CT could be a highly cost-saving
imaging modalities in comparison to MRI for
postoperative patients with recurrent and persistent
lower limb pain (Van den Wyngaert et al 2018).
Furthermore, each SPECT-CT is £118 which is £12
cheaper than MRI (NHS Improvement n.d.). SPECT-CT
seems to be useful in diagnosing post-traumatic and
postoperative long bone osteomyelitis patients with
structurally abnormal bone, thus could be considered as
an alternative to MRI.
Conclusion
Radiological evaluation plays a critical role in the
diagnosis and management of postoperative long bone
osteomyelitis. Plain radiographs should be first line to
exclude other differentials such as fractures. CT and USS
can allow detect the osseous changes which can aid
with aspiration and biopsy. MRI should be next and is
the most useful imaging to establish postoperative long
bone osteomyelitis as it can detect early signs such as
bone marrow oedema. With the addition of MARS for CT
and MRI, their relative utility will be increased in patients
with metalwork. If MRI is contraindicated, CT is an
alternative. If the CT and MRI imaging is degraded by
metal artefacts, nuclear medicine scans such as triple
phase bone scans, SPECT-CT, PET and gallium
scintigraphy can be used to localise the inflammation.
SPECT-CT shows promise through its cost-effectiveness
and should be used in post-traumatic patients with
structurally abnormal bone. PET can be indicated to
distinguish between postoperative infections and
postoperative healing. Gallium scintigraphy may be
indicated in immunosuppressed patients with low
leukocytes counts which are sufficient for radio-labelled
leukocytes scans. Finally, it is up to the treating
healthcare professional to choose what may best suit
depending on the healthcare system.
Key phrases
1. Incidence of long bone infections is rising.
2. Definitive diagnosis of long bone osteomyelitis involves
a combination of clinical signs, laboratory tests and
imaging.
3. MRI is currently the best available imaging modality.
4. Alternative imaging modalities may be preferable in
specific clinical scenarios.
5. Imaging modalities are not completely risk free for
the patient.
No competing interests declared
ORCID iDs
Andrew Kailin Zhou https://orcid.org/0000-0001-6656-
8123
Milind Girish https://orcid.org/0000-0003-0599-5265
Jiang An Lim https://orcid.org/0000-0003-1610-7956
Xiaoyu Chen https://orcid.org/0000-0002-4727-731X
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long bones. Seminars in Plastic Surgery 23 59–72.
Choi S-J, Koch KM, Hargreaves BA, Stevens KJ, Gold GE 2014
Metal artifact reduction with MAVRIC SL at 3-T MRI in
patients with hip arthroplasty. American Journal of
Roentgenology 204 140–147.
Zhou et al. 19
is pertinent to understand other modalities of imaging
which are not limited by metal artefacts such as nuclear
imaging (Vaz et al 2017).
However, we are now able to use metal artefact
reduction sequence (MARS) MRIs which can minimise
the impact from metalwork. MARS consists of a variety
of techniques to reduce metal artefacts on MRI and can
be categorised into in-plane artefact reduction and
through-plane artefact reduction. In-plane artefact
reduction aims to reduce the effects of artefact in the
image plane through simple modifications of the scan
protocol such as 1.5 T magnet strength rather than 3 T,
increasing bandwidth during slice selection, maintaining
a good signal to noise ratio through increasing the
number of excitations (Hargreaves et al 2011). Through-
plane reduction involves reducing the effects of metal
artefacts in an adjacent plane. The MAVRIC-SL, a
combination of multiacquisition variable-resonance
image combination technique (MARVIC) and slice-
encoding for metal artefact correction (SEMAC), is used
for through-plane artefact reduction (Choi et al 2014).
Overall, MRI is the most useful diagnostic modality due
to its sensitivity in detecting early signs of long bone
osteomyelitis and high soft tissue resolution.
Triple-phase bone scan
Technetium-99m-labelled MDP (Tc99m-MDP) is
administered intravenously, and a three-phase image is
acquired consisting of the flow/perfusion, static tissue
and osseous phases (Palestro et al 2007). A positive
osteomyelitis sign involves presence of increased focal
perfusion, hyperaemia and bone activity (Schauwecker
1992). Because Tc99m-MDP uptake is dependent on
perfusion and bone formation (Galasko 1975), in
osteomyelitis, increased uptake correlates to increased
perfusion and invasion of microorganisms/leukocytes
which form the inflammatory reaction, consequentially
resulting in bone destruction (Mader et al n.d.). Although
triple phase bone scans are easily performed and
sensitive for postoperative long bone osteomyelitis, the
positive signs are not unique to long bone osteomyelitis
(Vaz et al 2017). Hyperperfusion, hyperaemia and
increased bone formation are all characteristic of bony
malignancies, trauma, aspect inflammation, heterotopic
ossification and any other cause of accelerated new
bone formation (Vaz et al 2017). Furthermore, Triple
phase bone scans are the most expensive scans costing
£198 per scan (NHS Improvement n.d.). Additionally,
triple-phase scans are difficult to interpret and can be
ambiguous, thus further imaging may be necessary to
obtain a definitive answer.
Gallium scintigraphy
Gallium scans can be used in conjunction with a triple-
phase bone scan to detect postoperative long bone
infection. Studies have demonstrated that triple-phase
bone scan accuracy ranged from 50 to 70% in infected
long bones, whilst Gallium used in conjunction with
triple-phase bone scans only marginally increased the
accuracy to 65–80% (Love et al 2009). The majority of
the circulating gallium is bound to transferrin, thus
increased blood perfusion results in increased gallium
at the inflammation site (Palestro et al 2007). Bacteria
uptake the gallium directly and through siderophores
(Palestro et al 2007). The gallium is seen on leukocytes
through phagocytosis of bacteria from macrophages and
gallium directly binding to the leukocytes (Palestro et al
2007). Gallium scintigraphy is useful in patients with a
low white cell count as it can detect osteomyelitis in
immunocompromised patients (Palestro 1994). The
current literature suggests that gallium scintigraphy may
be more useful in spinal osteomyelitis and may not be
indicated in postoperative long bone infections (Love et
al 2009, Termaat et al 2005). Limitations of gallium
scintigraphy include the large radiation exposure and
requirement of multiple imaging sessions, potentially
taking up to 48–72 h (Christian et al 2007). Similar to
triple-phase bone scans, uptake is dependent on
inflammation which is not exclusive to long bone
osteomyelitis.
Radio-labelled leukocytes (RLL)
RLL is an in vitro labelling technique utilising 111In-
oxine and 99mTc-exametazime to label the patient’s
leukocytes, most commonly neutrophils (Palestro et al
2007). RLL measures radiotracer accumulation in the
reticuloendothelial system. In order to differentiate
between bone marrow and leukocytes, the white cell
scan is combined with Tc99m-labelled colloid scan,
which maps out the bone marrow (Lee et al 2016). Any
disparity between the white cell scan and the bone
marrow scan is indicative of infection. RLL scans
combined with bone marrow scans are the most
effective in detecting infection in long bones with an
accuracy of approximately 90% across various studies
(Magnuson et al 1988, Pring et al 1986, Rand & Brown
1990). However, as the RLL are most commonly
neutrophils, the infections diagnosed may be limited to
bacterial. For opportunistic infection such as
mycobacterium or yeast, RLL may not be sensitive
enough; therefore, gallium scintigraphy may be preferred
in this scenario. A minimum total white count of
2000mL1 is necessary to achieve adequate
sensitivity (Palestro et al 2007). Furthermore, there have
been reports of two fatalities from cardiopulmonary
failure shortly after administration of the RLL; however,
the precise reasoning behind the fatalities is yet to be
clarified (Magnuson et al 1988). Another drawback
associated with the RLL scan is that it requires skilled
personnel to perform the procedure and it is not readily
available. Although RLL scans have the highest
accuracy, it seems that there are quite a few limitations
which have yet to be resolved.
Positron emission tomography (PET)
Fluorine-18-fluorodeoxyglucose positron emission
tomography (FDG-PET) is used to localise inflammation.
In inflammation and infection, FDG uptake is thought to
be raised due to a combination of increased expression
of glucose transporters on activated inflammatory cells
and a cytokine-mediated increase in affinity for
deoxyglucose from glucose transporters (Mochizuki et al
2001, Paik et al 2004). Although malignancies and
infection present similarly on FDG-PET, it is particularly
useful in localising the abnormality when it is difficult to
determine on other imaging such as MRI (Wang et al
2011). Indeed, Van Vielt et al demonstrated that FDG-
PET is a promising tool in discriminating between
aseptic and septic delayed union in the lower extremities
(van Vliet et al 2018). Furthermore, FDG-PET was proven
to be useful in postoperative patients in distinguishing
postoperative infection from postoperative bone healing
(Koort et al 2004), whilst Lankinen et al showed that
FDG may be effective in confirming low-grade bone
infections in culture negative patients (Lankinen et al
2017). Overall, FDG-PET proves to be a promising
prospect in the diagnosis of long bone infections in
postoperative patients.
SPECT-CT
SPECT-CT is useful in imaging osteomyelitis through
combining anatomical and functional aspects which
allows for more precise localisation of infection foci
(Thang et al 2014). In some cases of bone infection with
adjacent soft tissue involvement, planar images are not
able to distinguish soft tissue from bone infection and
SPECT-CT is able to more precisely define the extent of
infection. A study by Filippi and Schillaci found that
SPECT-CT correctly characterised and localised site
uptake in all suspected osteomyelitis patients and
discriminated between adjacent soft tissue involvement
and bone involvement (Filippi & Schillaci 2006). SPECT-
CT was particularly useful in patients with structural
bone abnormalities after traumatic injury (Filippi &
Schillaci 2006). After trauma, the structural
abnormalities persist and this makes it difficult for CT or
plain radiograph to detect infection because
morphological imaging may not detect infection in
structurally abnormal bone (Seabold et al 1989, Tumeh
et al 1987). Holger et al found that SPECT-CT has
improved specificity in comparison to SPECT alone when
diagnosis chronic osteomyelitis (89% vs. 78%,
respectively) (Horger et al 2003). Van den Wyngaert et al
found that SPECT-CT could be a highly cost-saving
imaging modalities in comparison to MRI for
postoperative patients with recurrent and persistent
lower limb pain (Van den Wyngaert et al 2018).
Furthermore, each SPECT-CT is £118 which is £12
cheaper than MRI (NHS Improvement n.d.). SPECT-CT
seems to be useful in diagnosing post-traumatic and
postoperative long bone osteomyelitis patients with
structurally abnormal bone, thus could be considered as
an alternative to MRI.
Conclusion
Radiological evaluation plays a critical role in the
diagnosis and management of postoperative long bone
osteomyelitis. Plain radiographs should be first line to
exclude other differentials such as fractures. CT and USS
can allow detect the osseous changes which can aid
with aspiration and biopsy. MRI should be next and is
the most useful imaging to establish postoperative long
bone osteomyelitis as it can detect early signs such as
bone marrow oedema. With the addition of MARS for CT
and MRI, their relative utility will be increased in patients
with metalwork. If MRI is contraindicated, CT is an
alternative. If the CT and MRI imaging is degraded by
metal artefacts, nuclear medicine scans such as triple
phase bone scans, SPECT-CT, PET and gallium
scintigraphy can be used to localise the inflammation.
SPECT-CT shows promise through its cost-effectiveness
and should be used in post-traumatic patients with
structurally abnormal bone. PET can be indicated to
distinguish between postoperative infections and
postoperative healing. Gallium scintigraphy may be
indicated in immunosuppressed patients with low
leukocytes counts which are sufficient for radio-labelled
leukocytes scans. Finally, it is up to the treating
healthcare professional to choose what may best suit
depending on the healthcare system.
Key phrases
1. Incidence of long bone infections is rising.
2. Definitive diagnosis of long bone osteomyelitis involves
a combination of clinical signs, laboratory tests and
imaging.
3. MRI is currently the best available imaging modality.
4. Alternative imaging modalities may be preferable in
specific clinical scenarios.
5. Imaging modalities are not completely risk free for
the patient.
No competing interests declared
ORCID iDs
Andrew Kailin Zhou https://orcid.org/0000-0001-6656-
8123
Milind Girish https://orcid.org/0000-0003-0599-5265
Jiang An Lim https://orcid.org/0000-0003-1610-7956
Xiaoyu Chen https://orcid.org/0000-0002-4727-731X
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infections. Seminars in Roentgenology 42 92–101.
Collins MS, Schaar MM, Wenger DE, Mandrekar JN 2005 T1-
weighted MRI characteristics of pedal osteomyelitis.
American Journal of Roentgenology 185 386–393.
Donovan A, Schweitzer ME 2010 Use of MR imaging in
diagnosing diabetes-related pedal osteomyelitis.
Radiographics 30 723–736.
Filippi L, Schillaci O 2006 Usefulness of hybrid SPECT/CT in
99mTc-HMPAO–labeled leukocyte scintigraphy for bone and
joint infections. Journal of Nuclear Medicine 47
1908–1913.
Galasko CSB 1975 The significance of occult skeletal
metastases, detected by skeletal scintigraphy, in patients
with otherwise apparently "early" mammary carcinoma.
British Journal of Surgery 62 694–696.
Hargreaves BA, Worters PW, Pauly KB, Pauly JM, Koch KM,
Gold GE 2011 Metal-induced artifacts in MRI. American
Journal of Roentgenology 197 547–555.
Horger M, Eschmann SM, Pfannenberg C, et al 2003 The value
of SPET/CT in chronic osteomyelitis. European Journal of
Nuclear Medicine and Molecular Imaging 30 1665–1673.
Jaramillo D 2011 Infection: musculoskeletal. Pediatric
Radiology 41 Suppl 1 S127–S134.
Koort JK, M€akinen TJ, Knuuti J, Jalava J, Aro HT 2004
Comparative 18F-FDG PET of experimental Staphylococcus
aureus osteomyelitis and normal bone healing. The Journal
of Nuclear Medicine 45 1406–1411.
Kremers HM, Nwojo ME, Ransom JE, Wood-Wentz CM, Melton
LJ, Huddleston PM 2015. Trends in the epidemiology of
osteomyelitis. Journal of Bone and Joint Surgery 97
837–845.
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HT 2017 Intensity of 18F-FDG PET uptake in culture-
negative and culture-positive cases of chronic osteomyelitis.
Contrast Media & Molecular Imaging 2017 9754293. DOI:
10.1155/2017/9754293
Lee YJ, Sadigh S, Mankad K, Kapse N, Rajeswaran G 2016 The
imaging of osteomyelitis. Quantitative Imaging in Medicine
and Surgery 6 184–198.
Lin EC 2010 Radiation risk from medical imaging. Mayo Clinic
Proceedings 85 (12) 1142–1146; quiz 1146.
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the infected joint replacement. The role of nuclear medicine
techniques in the evaluation of infectious disease (part I).
Seminars in Nuclear Medicine 39 66–78.
Mader JT, Shirtliff M, Calhoun JH n.d. Staging and Staging
Application in Osteomyelitis. Clinical Infectious Diseases 25
1303–1309.
Magnuson JE, Brown ML, Hauser MF, Berquist TH, Fitzgerald
RH, Klee GG 1988 In-111-labeled leukocyte scintigraphy in
suspected orthopedic prosthesis infection: comparison with
other imaging modalities. Radiology 168 235–239.
McKee MD, Li-Bland EA, Wild LM, Schemitsch EH 2010 A
prospective, randomized clinical trial comparing an
antibiotic-impregnated bioabsorbable bone substitute with
standard antibiotic-impregnated cement beads in the
treatment of chronic osteomyelitis and infected nonunion.
Journal of Orthopaedic Trauma 24 483–490.
McNally MA, Ferguson JY, Lau ACK, Diefenbeck M,
Scarborough M, Ramsden AJ, Atkins BL 2016 Single-stage
treatment of chronic osteomyelitis with a new absorbable,
gentamicin-loaded, calcium sulphate/hydroxyapatite
biocomposite: a prospective series of 100 cases. The Bone
& Joint Journal 98-B 1289–1296.
Miller TT, Randolph DA, Staron RB, Feldman F, Cushin S 1997
Fat-suppressed MRI of musculoskeletal infection: fast T2-
weighted techniques versus gadolinium-enhanced T1-
weighted images. Skeletal Radiology 26 654–658.
Mochizuki T, Tsukamoto E, Kuge Y, et al 2001 FDG uptake and
glucose transporter subtype expressions in experimental
tumor and inflammation models. Journal of Nuclear
Medicine 42 1551–1555.
National Tariff Payment System | NHS Improvement [WWW
Document], n.d. https://improvement.nhs.uk/resources/
national-tariff/#h2-tariff-documents (accessed 19 June
2020).
Paik J-Y, Lee K-H, Choe YS, Choi Y, Kim B-T 2004 Augmented
18F-FDG uptake in activated monocytes occurs during the
priming process and involves tyrosine kinases and protein
kinase C. Journal of Nuclear Medicine 45 124–128.
Palestro CJ 1994 The current role of gallium imaging in
infection. Seminars in Nuclear Medicine 24 128–141.
Palestro CJ, Love C, Miller TT 2007 Diagnostic imaging tests
and microbial infections. Cell Microbiology 9 2323–2333.
Pineda C, Espinosa R, Pena A 2009 Radiographic imaging in
osteomyelitis: the role of plain radiography, computed
tomography, ultrasonography, magnetic resonance imaging,
and scintigraphy. Seminars in Plastic Surgery 23 80–89.
Pring DJ, Henderson RG, Keshavarzian A, Rivett AG, Krausz T,
Coombs RR, Lavender JP 1986 Indium-granulocyte
scanning in the painful prosthetic joint. American Journal of
Roentgenology 147 167–172.
Pugmire BS, Shailam R, Gee MS 2014 Role of MRI in the
diagnosis and treatment of osteomyelitis in pediatric
patients. World Journal of Radiology 6 530–537.
Rand JA, Brown ML 1990 The value of indium 111 leukocyte
scanning in the evaluation of painful or infected total knee
arthroplasties. Clinical Orthopaedics 259 179–182.
Schauwecker DS 1992 The scintigraphic diagnosis of
osteomyelitis. American Journal of Roentgenology 158
9–18.
Seabold JE, Nepola JV, Conrad GR, Marsh JL, Montgomery WJ,
Bricker JA, Kirchner PT 1989 Detection of osteomyelitis at
fracture nonunion sites: comparison of two scintigraphic
methods. American Journal of Roentgenology 152
1021–1027.
Termaat MF, Raijmakers PG, Scholten HJ, Bakker FC, Patka P,
Haarman HJ 2005 The accuracy of diagnostic imaging for
the assessment of chronic osteomyelitis: a systematic
review and meta-analysis. The Journal of Bone and Joint
Surgery. American Volume 87 2464–2471.
Thang SP, Tong AKT, Lam WWC, Ng DC-E 2014 SPECT/CT in
Musculoskeletal Infections. Seminars in Musculoskeletal
Radiology 18 194–202.
Tumeh SS, Aliabadi P, Weissman BN, McNeil BJ 1987 Disease
activity in osteomyelitis: role of radiography. Radiology 165
781–784.
Van den Wyngaert T, Palli SR, Imhoff RJ, Hirschmann MT 2018
Cost-effectiveness of bone SPECT/CT in painful total knee
arthroplasty. Journal of Nuclear Medicine 59 1742–1750.
van Vliet KE, de Jong VM, Termaat MF, Schepers T, van Eck-
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