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Screening with angiographic images prior to 99mTc-HMPAO labelled leukocyte scintigraphy in the diagnosis of periprosthetic infection
Cribado mediante angiogammagrafía previo a la realización de gammagrafía con leucocitos 99mTc-HMPAO en el diagnóstico de infección de prótesis articulares
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La fase ósea evidencia captación difusa periprotésica con predominio en la punta del vástago femoral (C). En la GL se observan depósitos focales en la articulación coxofemoral izquierda con trayecto fistuloso hacia la cara externa del muslo (D).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "U. Granados, D. Fuster, A. Soriano, S. García, G. Bori, J.C. Martínez, M. Mayoral, P. Perlaza, X. Tomás, F. Pons" "autores" => array:10 [ 0 => array:2 [ "nombre" => "U." "apellidos" => "Granados" ] 1 => array:2 [ "nombre" => "D." "apellidos" => "Fuster" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Soriano" ] 3 => array:2 [ "nombre" => "S." "apellidos" => "García" ] 4 => array:2 [ "nombre" => "G." "apellidos" => "Bori" ] 5 => array:2 [ "nombre" => "J.C." "apellidos" => "Martínez" ] 6 => array:2 [ "nombre" => "M." "apellidos" => "Mayoral" ] 7 => array:2 [ "nombre" => "P." "apellidos" => "Perlaza" ] 8 => array:2 [ "nombre" => "X." 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Bone scintigraphy after the administration of <span class="elsevierStyleSup">99m</span>Tc-HDP. (A) Whole body scan shows focal increased uptake in the middle third of the left tibia. (B) In the SPECT-CT images the lesion can be pinpointed to the medial surface of the tibia.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.R. Infante, R. Lorente, J.I. Rayo, J. Serrano, M.L. Domínguez, L. García, M. Moreno" "autores" => array:7 [ 0 => array:2 [ "nombre" => "J.R." "apellidos" => "Infante" ] 1 => array:2 [ "nombre" => "R." "apellidos" => "Lorente" ] 2 => array:2 [ "nombre" => "J.I." "apellidos" => "Rayo" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Serrano" ] 4 => array:2 [ "nombre" => "M.L." "apellidos" => "Domínguez" ] 5 => array:2 [ "nombre" => "L." "apellidos" => "García" ] 6 => array:2 [ "nombre" => "M." "apellidos" => "Moreno" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S2253654X15000050" "doi" => "10.1016/j.remn.2015.01.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2253654X15000050?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2253808915000580?idApp=UINPBA00004N" "url" => "/22538089/0000003400000004/v1_201506250030/S2253808915000580/v1_201506250030/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Screening with angiographic images prior to <span class="elsevierStyleSup">99m</span>Tc-HMPAO labelled leukocyte scintigraphy in the diagnosis of periprosthetic infection" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "219" "paginaFinal" => "224" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "U. Granados, D. Fuster, A. Soriano, S. García, G. Bori, J.C. Martínez, M. Mayoral, P. Perlaza, X. Tomás, F. Pons" "autores" => array:10 [ 0 => array:4 [ "nombre" => "U." "apellidos" => "Granados" "email" => array:1 [ 0 => "ulgranad@clinic.ub.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "D." "apellidos" => "Fuster" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Soriano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "S." 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"apellidos" => "Tomás" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 9 => array:3 [ "nombre" => "F." "apellidos" => "Pons" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Nuclear, Hospital Clínic, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Enfermedades Infecciosas, Hospital Clínic, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Traumatología y Ortopedia, Hospital Clínic, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Radiodiagnóstico, Hospital Clínic, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cribado mediante angiogammagrafía previo a la realización de gammagrafía con leucocitos <span class="elsevierStyleSup">99m</span>Tc-HMPAO en el diagnóstico de infección de prótesis articulares" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2208 "Ancho" => 2918 "Tamanyo" => 531928 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Patient with complete left knee prosthesis with negative blood flow phase (A), hyperemia in the blood pool phase (B), periprosthetic uptake in the delayed bone phase, predominantly on the tibial component, suggesting loosening (C). The LS does not show leukocyte uptake which would suggest infection (D). 14 months follow up of this patient without antibiotic treatment, did not produce clinical evidence of infection.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In developed countries the incidence of hip and knee arthroplasty has increased considerably in the last decade, especially as a result of population aging, biomedical technology and increased life expectancy in patients with chronic illness.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> In the USA about 700,000 joint replacements are carried out on an annual basis.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> In Spain it is estimated that up to 30,000 arthroplasty procedures are performed per year.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Although prostheses increase the quality of life of patients, they may involve multiple complications, such as aseptic loosening or periprosthetic infection.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> Infection is the most serious complication, with an incidence of 0.8–1.9% in knee replacements, and between 0.3% and 1.7% with hip arthroplasty.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Patients with chronic diseases such as rheumatoid arthritis and diabetes, obese patients and patients with multiple previous surgical interventions are particularly affected by infection.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> Up to about 70% of all prosthetic infections occur within the first 2 years of surgery,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> the most common microorganisms being <span class="elsevierStyleItalic">Staphylococcus epidermidis</span> (31%) and <span class="elsevierStyleItalic">Staphylococcus aureus</span> (20%).<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">A simple X-ray, the initial step for the evaluation of a painful prosthesis, is sufficient to identify the cause of pain in only 25% of cases.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> Therefore, in most patients other imaging methods to discern etiology are usually required. The presence of artifacts created by the metallic components of joint replacements limit the capabilities of CT and MRI scans. Arthrocentesis is an invasive technique and the results are frequently inconclusive, having a high false positive rate due to contamination and elevated false negative rate because of difficulties in obtaining a sufficient sample for diagnosis. Markers of inflammation such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) have high sensitivity, but low specificity, and often cannot differentiate an aseptic loosening from an infection because levels may be elevated in both clinical situations.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Bone scintigraphy (BS) and scintigraphy with <span class="elsevierStyleSup">99m</span>Tc-HMPAO labeled leukocytes (LS) are the most widely used imaging techniques in the study of joint replacements for the differential diagnosis between aseptic loosening and infection. The LS is highly sensitive and demonstrates specificity that can reach 80–100% when analyzed by an expert specialist or evaluated in conjunction <span class="elsevierStyleSup">99m</span>Tc-colloid bone marrow scintigraphy which facilitates the differentiation between activation of bone marrow adjacent to the prosthesis from a true periprosthetic infection.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">It has been reported that the analysis of the three-phase BS has a high negative predictive value of 90–93% in detecting periprosthetic infection.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">12,13</span></a> However, in most cases with aseptic loosening the blood pool phase and the bone phase in BS usually come up positive, so that the overall performance as a screening test is low.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> So far the different phases of BS as a possible screening method for the diagnosis of infection of joint replacements have not been studied independently.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The aim of this paper is to analyze whether angiographic images may be useful as a screening method for the diagnosis of prosthetic joint infection, prior to LS.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients</span><p id="par0040" class="elsevierStylePara elsevierViewall">In this prospective study, 120 patients were studied consecutively (70 women and 50 men) with a mean age of 71<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>11 years, with total hip (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>63) or knee (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>57) replacement. The average time since the replacement surgery was 78<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>76 months. The inclusion criterion was clinical suspicion of septic loosening of the prosthesis. ESR and CRP were determined, BS was performed in 3 phases and LS carried out in all patients. Normal values were 1–20<span class="elsevierStyleHsp" style=""></span>mm/h for ESR and 0–1<span class="elsevierStyleHsp" style=""></span>mg/dl for CRP. In patients undergoing replacement of the prosthesis, the definitive diagnosis was performed by sampling and subsequent microbiological analysis. In patients not undergoing surgery, infection was excluded from diagnosis when, during a clinical follow-up period of at least 12 months, in the absence of specific antibiotic treatment, no signs of active infection were found.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Microbiological analysis</span><p id="par0045" class="elsevierStylePara elsevierViewall">An average of 8 periprosthetic samples were taken, if two or more samples were positive for the same organism results were considered positive for infection. Samples were collected by joint fluid aspiration, swab smears in standard culture medium and periprosthetic tissue biopsy.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Imaging techniques</span><p id="par0050" class="elsevierStylePara elsevierViewall">In order to carry out the BS, an intravenous bolus injection 925<span class="elsevierStyleHsp" style=""></span>MBq of <span class="elsevierStyleSup">99m</span>Tc-HMDP was administered for study with the patient placed under the camera. The blood flow phase consisted of a dynamic study in anterior and posterior projection obtaining 60<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>s images in word mode for 1<span class="elsevierStyleHsp" style=""></span>min with a 128<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>128 matrix and at zoom 1. The detection field was focused on the prosthesis of study. Next, 2–4<span class="elsevierStyleHsp" style=""></span>min post-injection, 90<span class="elsevierStyleHsp" style=""></span>s static images were acquired without changing the position of the patient (blood pool phase). Finally, 2<span class="elsevierStyleHsp" style=""></span>h after injection, images were taken of the area of study in word mode for 300<span class="elsevierStyleHsp" style=""></span>s with a matrix of 256<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>256 (bone phase).</p><p id="par0055" class="elsevierStylePara elsevierViewall">For the LS autologous leukocytes were obtained from the patient for cell labeling with 185<span class="elsevierStyleHsp" style=""></span>MBq of <span class="elsevierStyleSup">99m</span>Tc-HMPAO. Four hours after reinjection of the labeled leukocytes, 600<span class="elsevierStyleHsp" style=""></span>s images were taken in anterior and posterior projection for hip prostheses, and for knee replacements, from the anterior, posterior, and both lateral aspects.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Image interpretation</span><p id="par0060" class="elsevierStylePara elsevierViewall">The evaluation of the BS and LS images was performed visually by 3 independent observers. Analyzing images of each phase (blood flow, blood pool and bone phase) of the BS independently, 2 categories (either positive or negative for periprosthetic infection) were considered. The GL was considered positive for infection when there was any extra-medullary periprosthetic uptake. If the three observers did not agree on the same result, either positive or negative for infection, the result coinciding with two observers was selected.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistics</span><p id="par0065" class="elsevierStylePara elsevierViewall">Sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) were calculated using the standard methods. The variables were compared using the Student's <span class="elsevierStyleItalic">t</span> test for ESR and CRP and were considered to be statistically significant when <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05. The kappa index was calculated to establish the degree of inter-observer concordance.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">In 18 of the 120 patients included in the study (15%), infection of the joint prosthesis was diagnosed: 10/63 (16%) of patients with hip replacements and 8/57 (14%) patients with knee replacements. The most common isolated microorganism was <span class="elsevierStyleItalic">Staphylococcus epidermidis</span> (50%). In the other 102 of 120 cases, infection was ruled out, by negative cultures after surgical replacement of the prosthesis (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>42) or by clinical observation (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>60). The ESR and CRP in the group of patients with prosthesis infection were significantly higher than in the group of patients without infection (51<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>44 vs 20<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>22 for ESR and 2.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.86 vs 1.4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.2 for CRP; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.01). The sensitivity and specificity of ESR were 58% and 71% and of CRP 75% and 50%, respectively.</p><p id="par0075" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the main clinical and laboratory parameters of patients included in this study.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">The blood flow was positive in 15/18 patients with infection of the prosthesis and in 21/102 patients without infection, showing a sensitivity and a specificity of 83% and 79% respectively, and NPV and PPV of 97% and 42% (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> and <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In patients without infection vs patients with prosthesis infection, results of the vascular or blood pool phase of the BS were positive in 56% and 83%, and delayed (bone phase) images gave positive results in 87% of non-infected patients and 100% of infected. LS showed a sensitivity of 72% and a specificity of 95% (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The inter-observer concordance (kappa index with a confidence interval of 95%) in assessing the results of the scintigraphic imaging was blood flow phase 0.92 (range 0.85–1), blood pool phase 0.81 (range 0.81–0.98), bone phase 0.8 (range 0.61–0.99).</p><p id="par0090" class="elsevierStylePara elsevierViewall">In 3 of 10 patients with infected hip prostheses, both the angiogram and the LS gave a negative diagnosis. In all 3 cases the causative agent was <span class="elsevierStyleItalic">Staphylococcus epidermidis</span>, and all cases showed a normal PCR.</p><p id="par0095" class="elsevierStylePara elsevierViewall">In 2 of 8 patients with infected (coagulase negative staphylococcus) knee replacements, LS was negative and blood flow phase positive. There were no cases found of periprosthetic infection with a positive LS and a false negative blood flow phase.</p><p id="par0100" class="elsevierStylePara elsevierViewall">In our study we have shown that if LS were performed exclusively on patients presenting positive blood flow phase, the number of LS carried out could be reduced by 82% in patients with hip replacements, and by 56% in patients with knee prosthesis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>); an overall reduction of 70% compared to the low reduction rate if we were to consider the other phases of the BS, independently or combined (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">The treatment for mechanical loosening is an implant revision or prosthetic replacement. However, in cases where the cause of loosening corresponds to an infectious complication (septic loosening) a two-step removal and replacement procedure is necessary which may or may not involve local antibiotic administration and prolonged systemic antibiotherapy; so prudent differential diagnosis is of great importance.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> ESR and CRP, with high levels of sensitivity and specificity, have proven useful in ruling out of prosthetic joint infection.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> Both tests have been used as a screening method in the diagnostic algorithms of the American Academy of Orthopedic Surgeons.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> According to our data, the ESR and CRP values were significantly higher in patients with periprosthetic infection; however, these parameters showed relatively low sensitivity (ESR 58% and CRP 71%) and specificity (ESR 75% and CRP 50%). Our results are consistent with studies by Nagoya et al.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> who showed that although the elevated ESR and CRP are suggestive of infection, some patients with prosthetic infection may show normal levels of these parameters and patients without infection may present abnormal levels.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Of the patients included in the study, infection was diagnosed in 16% of the hip replacements and in 14% of the knee prosthesis. The most common microorganism (50%) was <span class="elsevierStyleItalic">Staphylococcus epidermidis</span>, which follows the patterns of larger epidemiological studies.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">8,10</span></a> In cases where infection was ruled out, the most common diagnosis was mechanical loosening (71%), followed by mechanical overload (16%) which is probably identifying future loosening. There were no significant differences in the average time from replacement surgery between the group of patients with prosthetic infection and patients without infection, although it was slightly shorter time period when the prostheses were not infected.</p><p id="par0115" class="elsevierStylePara elsevierViewall">The LS showed sensitivity of 72% and a specificity of 95%, which when compared to previous studies, are lower values. In previous studies, with a similar specificity, sensibility reached values higher than 90%<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">9,11</span></a> however, these authors studied BS, SL and bone marrow scintigraphy simultaneously.</p><p id="par0120" class="elsevierStylePara elsevierViewall">It has been widely reported in scientific literature that BS can detect persistent uptake up to 12 months after replacement surgery and in clinical practice even longer, so it is of little use to differentiate between aseptic loosening and infection.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a> In our series of patients, the bone phase of the BS was positive in 100% of patients with infection and in 87% of patients in the group without infection. However, a systematic review showed that diagnosis of periprosthetic infection using three-phase BS was highly useful, with up to 80% accuracy for hip and 81% for knee replacements, thus representing an effective detection method periprosthetic infection.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Nagoya et al.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> concluded that the three-phase BS could be useful for the detection of periprosthetic infection because serological tests such as ESR and CRP and radiological findings are not always reliable.</p><p id="par0130" class="elsevierStylePara elsevierViewall">The authors specified a diagnosis of infection when the 3 BS phases were positive, 88% of cases in the group of patients with a prosthetic infection were diagnosed correctly. However, the false positive rate reached 10% in the group of patients not infected. Interestingly, in this series of patients, the blood flow phase was found to successfully read negative in the group of patients without infection, suggesting that the blood flow phase can rule out infection in aseptic cases. In our series of patients, the blood flow phase was positive in 83% of patients with prosthesis infection and in 20% of patients without infection, showing sensitivity of 83% and specificity of 79%. Of the 10 patients with an infected hip replacement, there were 3 cases which came up negative both in the blood flow phase and the LS. The bacterial agent was <span class="elsevierStyleItalic">Staphylococcus epidermidis</span> in all the cases. The CRP results were all normal, suggesting little inflammatory response, and hence lower hyperemia, which in turn would explain the negative blood flow phase. In the 8 patients with infected knee prosthesis we did not find a single false negative in the blood flow phase.</p><p id="par0135" class="elsevierStylePara elsevierViewall">In our study with three-phase BS, the high NPV of the blood flow phase stands out, reaching up to 97%, suggesting that it could be a suitable screening technique for prosthetic joint infection. We did not find any cases of an infected patient having positive LS and a false negative blood flow phase, which would have invalidated its use as a screening technique. The greatest advantage of a three-phase BS is that it would allow the use of LS to be reduced, limiting it to patients with a positive blood flow phase, without decreasing the LS sensitivity. Routine practice of three-phase BS would lead to a reduction in the number of LS procedures carried out, 82% less in cases of hip prostheses and 56% of cases of knee, leading to an overall reduction of 70%.</p><p id="par0140" class="elsevierStylePara elsevierViewall">In conclusion, the blood flow phase has been shown to be an adequate and reliable screening technique in the diagnosis of suspected infection of hip and knee in this series of patients. In carrying out a three phase BS in these patients, a LS procedure can be avoided in a significant number of cases, minimizing radiation dose, lowering costs, saving time dedicated to the cell labeling of the leukocytes, and therefore speeding up the diagnosis process in these patients.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres526474" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Aim" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec546660" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres526473" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec546661" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patients" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Microbiological analysis" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Imaging techniques" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Image interpretation" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Statistics" ] ] ] 6 => array:2 [ "identificador" => "sec0040" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-08-29" "fechaAceptado" => "2014-10-14" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec546660" "palabras" => array:5 [ 0 => "Angioscintigraphy" 1 => "Screening" 2 => "Joint infection" 3 => "<span class="elsevierStyleSup">99m</span>Tc-HMPAO-leukocyte" 4 => "Joint prosthesis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec546661" "palabras" => array:5 [ 0 => "Angiogammagrafía" 1 => "Cribado" 2 => "Infección" 3 => "<span class="elsevierStyleSup">99m</span>Tc-HMPAO-leucocitos" 4 => "Prótesis articulares" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Aim</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To evaluate the impact of the angioscintigrapy of the three phase bone scan as screening method to rule out infection of the hip and knee prosthesis prior to performing the <span class="elsevierStyleSup">99m</span>Tc-HMPAO leukocyte scintigraphy.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A total of 120 (70 women, 50 men; mean age 71<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>11<span class="elsevierStyleHsp" style=""></span>years) with clinical suspicion of hip (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>63) or knee (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>57) infection of the prosthesis and clinical suspicion of infection were evaluated prospectively. All patients underwent three-phase bone scan (angioscintigraphy, vascular and bone phase) and <span class="elsevierStyleSup">99m</span>Tc-HMPAO-labeled white blood cell scintigraphy. Final diagnosis of infection was made by microbiological documentation or clinical follow-up for at least 12 months.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Eighteen out of 120 patients were diagnosed of infection of hip prosthesis (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>10) or knee prosthesis (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>8). The angioscintigraphy was positive in 15/18 infected cases and in 21/102 of the non-infected cases with a sensitivity of 83%, specificity of 79% and negative predictive value of 97%. Sensitivity and specificity of <span class="elsevierStyleSup">99m</span>Tc-HMPAO leukocyte scintigraphy were 72% and 95%, respectively. If the leukocyte labeled scintigraphies had been used exclusively for patients with positive angioscintigraphy, this would have saved up to 70% of the <span class="elsevierStyleSup">99m</span>Tc-HMPAO leukocyte scintigraphies performed. There were no cases of infection with positive labeled leukocyte scintigraphy and negative angioscintigraphy.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Angioscintigraphy (blood flow phase of bone scan) is a useful technique for screening for hip and knee joint prosthesis infection, significantly reducing the need for <span class="elsevierStyleSup">99m</span>Tc-HMPAO leukocyte scintigraphy without affecting the sensitivity of the technique.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Aim" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Analizar la utilidad de la fase angiogammagráfica de la gammagrafía ósea en 3<span class="elsevierStyleHsp" style=""></span>fases como posible método de cribado en el diagnóstico de infección de prótesis de cadera y de rodilla, previa a la realización de la gammagrafía con leucocitos marcados.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se analizaron prospectivamente 120 pacientes (70 mujeres y 50 hombres) con edad media de 71<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>11<span class="elsevierStyleHsp" style=""></span>años y sospecha clínica de infección de prótesis de cadera (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>63) o rodilla (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>57), a los que se realizó gammagrafía ósea en 3<span class="elsevierStyleHsp" style=""></span>fases (angiogammagrafía, fase vascular y fase ósea) y gammagrafía con leucocitos marcados con <span class="elsevierStyleSup">99m</span>Tc-HMPAO. El diagnóstico definitivo se realizó mediante estudio microbiológico o seguimiento clínico mínimo de 12<span class="elsevierStyleHsp" style=""></span>meses.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se estableció el diagnóstico de infección de la prótesis articular en 18/120 pacientes: 10 pacientes con prótesis de cadera y 8 pacientes con prótesis de rodilla. La angiogammagrafía fue positiva en 15/18 pacientes infectados y en 21/102 pacientes no infectados, mostrando una sensibilidad del 83%, una especificidad del 79% y un valor predictivo negativo del 97%. La gammagrafía con leucocitos marcados mostró una sensibilidad y una especificidad del 72 y del 95%, respectivamente. Si se realizara la gammagrafía con leucocitos marcados exclusivamente a los pacientes con angiogammagrafía positiva, se reduciría un 70% de gammagrafías con leucocitos practicadas. No hubo ningún caso de infección con gammagrafía con leucocitos marcados positiva y angiogammagrafía negativa.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La angiogammagrafía es una buena técnica de cribado de infección de prótesis articulares de cadera y rodilla, disminuyendo significativamente el número de gammagrafías con leucocitos marcados, sin afectar la sensibilidad de la técnica.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as: Granados U, Fuster D, Soriano A, García S, Bori G, Martínez JC, et al. Cribado mediante angiogammagrafía previo a la realización de gammagrafía con leucocitos <span class="elsevierStyleSup">99m</span>Tc-HMPAO en el diagnóstico de infección de prótesis articulares. Rev Esp Med Nucl Imagen Mol. 2015;34:219–224.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2167 "Ancho" => 3002 "Tamanyo" => 518948 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Patient with infection of the complete hip replacement secondary to <span class="elsevierStyleItalic">Staphyloccocus epidermidis</span> showing hyperemia in the angiogram (A) and increased blood pool activity (B). The delayed bone phase shows diffuse periprosthetic uptake predominantly around the tip of the prosthesis (C). In the LS there are foci in the left acetabulo-femoral joint with a fistulous route toward the external thigh (D).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2208 "Ancho" => 2918 "Tamanyo" => 531928 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Patient with complete left knee prosthesis with negative blood flow phase (A), hyperemia in the blood pool phase (B), periprosthetic uptake in the delayed bone phase, predominantly on the tibial component, suggesting loosening (C). The LS does not show leukocyte uptake which would suggest infection (D). 14 months follow up of this patient without antibiotic treatment, did not produce clinical evidence of infection.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">N</span>: Normal values; ns: nonsignificance.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group with infection \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group without infection \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Number</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">102 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Prosthesis type</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hip \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">53 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Knee \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">49 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Scintigraphic diagnosis</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Infection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Without abnormality (BS &LS) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Aseptic loosening \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">72 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mechanical overload \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Pelvic fracture \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Patellar chondropathy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Microorganism</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Staphylococcus epidermidis</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Coagulase-negative <span class="elsevierStyleItalic">Staphylococcus</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Staphylococcus aureus</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Polymicrobial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">ESR (N: 1–20</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">mm/h)</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">51<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>22 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">CRP (N: 0–1</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">mg/dL)</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">**</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.86 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Average time since replacement (p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">=</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">ns)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">51<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>56 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab848233.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="npar0005"><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.0041.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "**" "nota" => "<p class="elsevierStyleNotepara" id="npar0010"><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.061.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Clinical and laboratory parameters comparing the group of patients diagnosed as having of periprosthetic infection with the group of patients without infection.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group with infection \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group without infection \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Blood flow (hip and knee)</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Positive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">81 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Sensitivity<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>83%/specificity<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>79%</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Blood flow (hip)</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Positive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Sensitivity<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>70%/specificity<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>93%</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Blood flow (knee)</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Positive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Sensitivity<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>100%/specificity<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>66%</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab848231.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Angiogram results, according to type of prosthesis and patient infection group.</p>" ] ] 4 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group with infection \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group without infection \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">BS (blood pool phase)</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Positive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Sensitivity<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>83%/specificity<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>44%</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">BS (bone phase)</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Positive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">89 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Sensitivity<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>100%/specificity<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>13%</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">LS</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Positive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">97 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Sensitivity<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>72%/specificity<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>95%</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab848232.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Infection diagnosis results obtained in the blood pool phase, bone phase of BS and LS.</p>" ] ] 5 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Prosthesis \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Blood flow \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Blood pool \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Bone phase \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">3-phase BS \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hip \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">82% (52) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57% (36) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13% (8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13% (8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Knee \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56% (32) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21% (12) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9% (5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7% (4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hip and knee \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70% (84) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40% (48) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11% (13) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10% (12) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab848234.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Reduction of scintigraphy with labeled leukocytes using the different phases of bone scintigraphy as screening.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0080" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Incidencia y factores asociados a la 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| Year/Month | Html | Total | |
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| 2023 March | 1 | 2 | 3 |
| 2018 February | 6 | 5 | 11 |
| 2018 January | 8 | 7 | 15 |
| 2017 December | 5 | 6 | 11 |
| 2017 November | 6 | 6 | 12 |
| 2017 October | 4 | 4 | 8 |
| 2017 September | 4 | 2 | 6 |
| 2017 August | 12 | 6 | 18 |
| 2017 July | 6 | 4 | 10 |
| 2017 February | 1 | 0 | 1 |
| 2016 November | 0 | 1 | 1 |
| 2016 October | 0 | 2 | 2 |
| 2016 September | 0 | 1 | 1 |
| 2016 August | 0 | 3 | 3 |
| 2016 July | 0 | 1 | 1 |
| 2016 June | 0 | 2 | 2 |
| 2016 May | 0 | 3 | 3 |
| 2016 April | 0 | 1 | 1 |
| 2016 March | 0 | 1 | 1 |
| 2016 February | 0 | 2 | 2 |
| 2016 January | 0 | 1 | 1 |
| 2015 July | 0 | 1 | 1 |
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