kantonsspital baselland spect/ct imaging
TRANSCRIPT
05/03/2013
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SPECT/CT Imaging
Knee & Hip Prosthesis
Helmut Rasch, Michael T. Hirschmann
Institute of Radiology and Nuclear Medicine, Dept. Orthopaedic Surgery and Traumatology,
Kantonsspital Baselland-Bruderholz, Switzerland
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„ We greatly thank the following grantauthorities for their financial support of ourresearch.“
Flavio Forrer, Rolf Hügli, Niklaus F. Friederich, Faik K. Afifi, Enrique Testa, Milos Dordevic, Dominic Mathis, Stephan Schoen, Silvia Reichl, Anita Matt, Markus P. Arnold, Christopher Wagner
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Schedule
• Basics on Arthroplasty
• What is our SPECT/CT protocol?
• Why CT including extended Houndsfield scale?
• Cases
• Biomechanics – Why do we need it?
• Our experience- more to come….
• Conclusions
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Hip resurfacing not „en vogue“ anymore!Metal- on-metal bearing problem
Basics hip arthroplasty
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Short stem versus long stem
Basics hip arthroplasty
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Basics hip arthroplasty
Straight stem versus curved stemDifferent fixation conceptproximal, distal, combined
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Cemented versus uncemented stem► cemented: no ingrowth of bone, smooth surface
► cemented: ingrowth of bone; rotation stability due to rectangular shape; roughened surface
Basics hip arthroplasty
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uncementedscrew cup versus press-fitouter cup metal, inlay made of polyethylen, ceramic or metal
cementedoften polyethylen
Basics hip arthroplasty
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Unicondylar versus bicondylar knee arthroplasty
Basics knee arthroplasty
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„Unconstrained“ versus „constrained“
Basics knee arthroplasty
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„Unconstrained“ – „fixed versus mobile bearing“
Basics knee arthroplasty
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Basics knee arthroplasty
cemented hybriduncemented
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Examination protocoll – Scintigraphy & SPECT/CT
early 15min late ~40min
0 2‐3 h
• „perfusion phase“• „Bloodpool –phase“2 planes
• Whole body ap / pa• SPECT • and low dose CT
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3mm slices femoral head
0.7mm slices knee
3mm slices ankle joint
Modified
Imperial CT
protocol
(Henckel et al.
JBJS Br 2006
&
Hirschmann
et al. 2011
BMC Medical
Imaging)
4D-SPECT/CT Protocol
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SPECT/CT protocol – „biomechanical aquisition“
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CT image quality – importance of extended scale
1200HU 4000 HU
6500 HU 14000 HU
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Extended scale necessary? - YES
Up to 14000 HU
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Case examples
• The “typical“ case
• Uptake – always pathological?
• No Uptake – everything OK?
• Hypersensitivity reaction
• Infection
• Biomechanical knowledge – why we need it
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The “typical“ case
recurrent weight bearing, activity related pain 10 yrs after THA
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recurrent weight bearing, activity related pain 10 yrsafter THA
The “typical“ case
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The “typical“ case
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Does increased uptake always indicate a pathology?
Referred from GP for knee pain
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Cortical hypertrophy at distal fixation zone; ectopic ossificationRasch H, Hirschmann M, Huegli R. SPECT-CT - Prospects in Joint Imaging and Diagnostic Follow up after Arthroplasty Der Nuklearmediziner. 2012; 35 (03) :154-60. DOI http://dx.doi.org/ 10.1055/s-0032-1321822; Georg Thieme Verlag KG
Does increased uptake always indicate a pathology?
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No periprosthetic Uptake – everything OK?
Past right sided THA 1999; activity related pain in righthip
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No Uptake – everything OK?
Rasch H, Hirschmann M, Huegli R. SPECT-CT - Prospects in Joint Imaging and Diagnostic Follow up after Arthroplasty Der Nuklearmediziner. 2012; 35 (03) :154-60. DOI http://dx.doi.org/ 10.1055/s-0032-1321822; Georg Thieme Verlag KG
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Hypersensitivity reaction?
Past UKA 06/2011, past TKA 01/2012, burningsensation and pain, extension deficit
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Hypersensitivity reaction?
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Hypersensitivity reaction?
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Infection – 3 Phase scintigraphy
TKR 06/2005; Arthroscopy with biopsy 12/2011+ 10/2012; unexplained knee pain; suspicion of low grade infection
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Infection – SPECT/CT
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Infection – anti-granulocyte scintigraphy
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„A special case at the end“
TKA right 17.02.2011; past arthroscopic arthrolysis 3/2012persistent pain, indication for secondary patellar resurfacing
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„A special case at the end“
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Only patellar hyperpression?
Did you know what was wrong?
Look more closely!„A special case at the end“
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Biomechanics – Do we need it?
UKA 3 years ago, unexplained anterior knee pain
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Biomechanics – Do we need?
No patella problem - BUT.......
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Femoral alignment Combined alignment
UKA rotation alignment (internal-external)
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Biomechanics – Do we need it?
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Biomechanics – Do we need it?
TKA 2008; patellar resurfacing 2010; anterior knee pain
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Biomechanics – Do we need it?
6° Int 2° ant
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Biomechanics – own results!
• SPECT/CT tracer uptake related to TKA component position!• Unpublished data 200 painful TKA!
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• Distal versus proximal or
combined stem fixation
• Orientation and position of THR
• varus-valgus stem leads to
increased SPECT/CT distally
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Hirschmann MT et al.: A novel standardized algorithm for evaluating patients with painful TKA using combined single photon emission tomography and conventional computerized tomography; Knee Surg Sports Traumatol Arthrosc. 2010 Jul;18(7):939-44.
Combination of SPECT/CT tracer uptake and TKRcomponent position: new era of imaging!
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Biomechanics – software tool
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3D volumetric quantification and localization using
customised software
Hirschmann MT et al., BMC Medical Imaging 2012
Assessment of tracer uptake distribution and intentity
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Femoral alignment Tibial alignment
Varus-Valgus alignment (coronal)
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Femoral alignment Tibial alignment
Sagittal alignment (flexion-extension)
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Femoral alignment Tibial alignment
Rotational alignment (internal-external)
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NEW: biomechanical analysis in true 3-D
Biomechanical measurement of THA
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• Usage of true 3 D Landmarks
• Reproducible measurements
• Possibility to differentiate and correlate uptake patterns with biomechan
Biomechanical measurement of THA
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Conclusion
Mechanics and structure and biology
Mechanics
• mechanical alignment
• anatomical alignment
Structure
• bone
• Muscles
• Tendons
• Ligaments
Biology/Metabolism
SPECT + CT = SPECT/CT
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Questions you should ask to yoursurgeon
Age of implant
Type, design of prosthesis
Mode of fixation
Site of pain
Mechanical alignment
Loading pattern
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Tips from our experience Reducing scanning time
Radiation dose reduction
Improving image quality
- Extended CT scale
- Cut-out bladder uptake
Relative component position (e.g. bearing partners)
SPECT/CT can be helpful as early as 6mths after surgery
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Take home messages
• Use all information – metabolic, biomechnical and morphological information to obtain a correct diagnosis
• Prosthesis loosening does not always show an uptake
• Not every periprosthetic uptake is loosening or infection – look for biomechanics
• For correct intepretation you have to know the biomechanics of the implanted type of prosthesis (e.g. fixation of THA proximal or distal)
Talk to your surgeon – interdisciplinary approach
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