The availability of hybrid devices that combine the latest single-photon emission computed tomography (SPECT) imaging technology with multislice computed tomography (CT) scanning has allowed us to detect subtle, nonspecific abnormalities on bone scans and interpret them as specific focal areas of pathology. Abnormalities in the spine can be separated into those caused by pars fractures, facet joint arthritis, or osteophyte formation on vertebral bodies. Compression fractures can be distinguished from severe degenerative disease, both of which can cause intense activity across the spine on either planar or SPECT imaging. Localizing activity in patients who have had spinal fusion can provide tremendous insight into the causes of therapeutic failures. Infections of the spine now can be diagnosed with gallium SPECT/CT, despite the fact that gallium has long been abandoned because of its failure to detect spine infection on either planar or SPECT imaging. Small focal abnormalities in the feet and ankles can be localized well enough to make specific orthopedic diagnoses on the basis of their location. Moreover, when radiographic imaging provides equivocal or inadequate information, SPECT/CT can provide a road map for further diagnostic studies and has been invaluable in planning surgery. Our ability to localize activity within a bone or at an articular surface has allowed us to distinguish between fractures and joint disease. Increased activity associated with congenital anomalies, such as tarsal coalition and Bertolotti's syndrome have allowed us to understand the pathophysiology of these conditions, to confirm them as the cause of the patient's symptoms, and to provide information that is useful in determining appropriate clinical management. As our experience broadens, SPECT/CT will undoubtedly become an important tool in the evaluation and management of a wider variety of orthopedic patients.