The evolving role of nuclear medicine in osteomyelitis: A narrative review of current evidence and future horizons.

OBJECTIVE

The diagnosis of osteomyelitis (OM) remains a significant clinical challenge, often requiring a multimodality imaging approach to differentiate infection from non-infectious inflammatory conditions. This review focuses on primary and secondary osteomyelitis, with particular emphasis on fracture-related infections, sternal infections, and the assessment of dissemination of infection using nuclear medicine techniques, from established scintigraphic methods to advanced hybrid imaging and emerging technologies.

FINDINGS: While three-phase bone scintigraphy remains a highly sensitive initial screening tool, its utility is limited by low specificity. White blood cell (WBC) scintigraphy, particularly when combined with SPECT/CT offers superior specificity and is considered a cornerstone for diagnosing musculoskeletal infections. ¹⁸F-FDG PET/CT has emerged as a powerful modality with high diagnostic accuracy, especially for evaluating fracture-related infections or dissemination of infection. However, its performance can be confounded by sterile postsurgical inflammation, though specific uptake patterns and a high negative predictive value are clinically valuable. Emerging frontiers, including dynamic PET acquisition, AI-driven image enhancement, and novel pathogen-specific radiotracers, promise to overcome current limitations by improving specificity and providing biologically targeted information.

CONCLUSION

The integration of scintigraphic and hybrid imaging techniques, tailored to the specific clinical scenario, is paramount for the accurate diagnosis of OM. Future developments are rapidly moving the field from non-specific inflammation imaging toward precise, pathogen-targeted molecular diagnostics.