The diagnostic accuracy of 18F-FDG PET/CT in diagnosing fracture-related infections.
PURPOSE
18F-Fluorodeoxyglucose positron emission tomography (18F-FDG PET/CT) is frequently used to diagnose fracture-related infections (FRIs), but its diagnostic performance in this field is still unknown. The aims of this study were: (1) to assess the diagnostic performance of qualitative assessment of 18F-FDG PET/CT scans in diagnosing FRI, (2) to establish the diagnostic performance of standardized uptake values (SUVs) extracted from 18F-FDG PET/CT scans and to determine their associated optimal cut-off values, and (3) to identify variables that predict a false-positive (FP) or false-negative (FN) 18F-FDG PET/CT result.


METHODS
This retrospective cohort study included all patients with suspected FRI undergoing 18F-FDG PET/CT between 2011 and 2017 in two level-1 trauma centres. Two nuclear medicine physicians independently reassessed all 18F-FDG PET/CT scans. The reference standard consisted of the result of at least two deep, representative microbiological cultures or the presence/absence of clinical confirmatory signs of FRI (AO/EBJIS consensus definition) during a follow-up of at least 6 months. Diagnostic performance in terms of sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) was calculated. Additionally, SUVs were measured on 18F-FDG PET/CT scans. Volumes of interest were drawn around the suspected and corresponding contralateral areas to obtain absolute values and ratios between suspected and contralateral areas. A multivariable logistic regression analysis was also performed to identify the most important predictor(s) of FP or FN 18F-FDG PET/CT results.


RESULTS
The study included 156 18F-FDG PET/CT scans in 135 patients. Qualitative assessment of 18F-FDG PET/CT scans showed a sensitivity of 0.89, specificity of 0.80, PPV of 0.74, NPV of 0.91 and diagnostic accuracy of 0.83. SUVs on their own resulted in lower diagnostic performance, but combining them with qualitative assessments yielded an AUC of 0.89 compared to an AUC of 0.84 when considering only the qualitative assessment results (p = 0.007). 18F-FDG PET/CT performed <1 month after surgery was found to be the independent variable with the highest predictive value for a false test result, with an absolute risk of 46% (95% CI 27-66%), compared with 7% (95% CI 4-12%) in patients with 18F-FDG PET/CT performed 1-6 months after surgery.


CONCLUSION
Qualitative assessment of 18F-FDG PET/CT scans had a diagnostic accuracy of 0.83 and an excellent NPV of 0.91 in diagnosing FRI. Adding SUV measurements to qualitative assessment provided additional accuracy in comparison to qualitative assessment alone. An interval between surgery and 18F-FDG PET/CT of <1 month was associated with a sharp increase in false test results.
['Lemans|Justin V C|JVC|http://orcid.org/0000-0003-0917-1108', 'Hobbelink|Monique G G|MGG|', 'IJpma|Frank F A|FFA|', 'Plate|Joost D J|JDJ|', 'van den Kieboom|Janna|J|', 'Bosch|Paul|P|', 'Leenen|Luke P H|LPH|', 'Kruyt|Moyo C|MC|', 'Glaudemans|Andor W J M|AWJM|', 'Govaert|Geertje A M|GAM|']
D000293:Adolescent D000328:Adult D000368:Aged D005188:False Negative Reactions D005189:False Positive Reactions D005260:Female D019788:Fluorodeoxyglucose F18 D050723:Fractures, Bone D006801:Humans D007239:Infections D008297:Male D008875:Middle Aged D000072078:Positron Emission Tomography Computed Tomography D012189:Retrospective Studies D012680:Sensitivity and Specificity D055815:Young Adult
Diagnostic accuracy 18F-FDG PET/CT Fracture-related infections Infection Diagnostic performance Trauma Diagnosis Medical imaging Nuclear imaging Osteomyelitis