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Appropriateness Criteria

Variant 1: Suspected osteomyelitis or septic arthritis or soft tissue infection (excluding spine and diabetic foot). Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography area of interest Usually appropriate Limited Varies Varies 9 9 0 0 0 0 0 0 0 0 14
References Study Quality
6 (28366223) 4
5 (28483044) 4
2 (27726741) 4
US area of interest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 2 3 1 1 0 0 0 0
MRI area of interest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 0 2 1 0 1 0 0 0
MRI area of interest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 0 3 0 0 1 0 0 0
3-phase bone scan area of interest Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 1 1 0 0 0 0 0 0
CT area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 10 0 2 1 1 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 10 3 1 0 0 0 0 0 0
CT area of interest without IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 10 1 2 0 1 0 0 0 0
Variant 2: Suspected septic arthritis or soft tissue infection. Initial radiographs normal or with findings suggestive of joint effusion or soft tissue swelling. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US area of interest Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 3 3 5 2 1
References Study Quality
14 (22871216) 2
Image-guided aspiration area of interest Usually appropriate Limited Varies Varies 8 8 0 0 0 2 3 1 0 3 5
References Study Quality
10 (24293800) 4
8 (32783556) 4
9 (31128740) 4
MRI area of interest without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 0 4 4 5
References Study Quality
6 (28366223) 4
2 (27726741) 4
12 (22884398) 4
13 (34145466) 4
MRI area of interest without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 1 3 6 2 1
References Study Quality
6 (28366223) 4
2 (27726741) 4
12 (22884398) 4
13 (34145466) 4
CT area of interest with IV contrast Usually appropriate Limited Varies Varies 7 7 0 0 0 0 2 5 4 2 1
References Study Quality
11 (18025514) 4
4 (-3194802) 4
CT area of interest without IV contrast May be appropriate Limited Varies Varies 5 5 1 0 0 4 6 3 0 0 0
References Study Quality
11 (18025514) 4
4 (-3194802) 4
3-phase bone scan area of interest Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 5 0 3 4 1 1 0 0 0
References Study Quality
7 (27390160) 4
4 (-3194802) 4
CT area of interest without and with IV contrast Usually not appropriate Limited Varies Varies 1 1 8 2 4 0 0 0 0 0 0
References Study Quality
11 (18025514) 4
4 (-3194802) 4
Variant 3: Suspected osteomyelitis. Initial radiographs normal or with findings suggestive of osteomyelitis. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI area of interest without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 2 3 9
References Study Quality
24 (17885058) 3
27 (20180105) 3
23 (16037509) 3
26 (19098186) 3
25 (23164978) 4
13 (34145466) 4
MRI area of interest without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 0 3 6 4
References Study Quality
24 (17885058) 3
27 (20180105) 3
23 (16037509) 3
26 (19098186) 3
25 (23164978) 4
13 (34145466) 4
3-phase bone scan area of interest May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 0 1 7 6 0 0 0 0
References Study Quality
19 (17146681) 3
17 (21934545) M
18 (26897336) 4
3-phase bone scan and WBC scan and sulfur colloid scan area of interest May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 5 5 0 0 1 2 10 1 0 0 0
References Study Quality
16 (27742026) 4
15 (30675635) 4
3-phase bone scan and WBC scan area of interest May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 1 0 1 9 3 0 0 0
References Study Quality
17 (21934545) M
FDG-PET/CT area of interest May be appropriate Limited ☢☢☢☢ 10-30 mSv 5 5 0 0 0 3 11 0 0 0 0
References Study Quality
20 (23905618) 4
17 (21934545) M
18 (26897336) 4
22 (26547722) 2
21 (28451827) 4
15 (30675635) 4
WBC scan and sulfur colloid scan area of interest May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 1 4 9 0 0 0 0
References Study Quality
18 (26897336) 4
16 (27742026) 4
15 (30675635) 4
CT area of interest with IV contrast May be appropriate Limited Varies Varies 5 5 1 0 2 1 4 6 0 0 0
References Study Quality
11 (18025514) 4
CT area of interest without IV contrast May be appropriate Limited Varies Varies 5 5 0 1 3 2 5 2 1 0 0
References Study Quality
11 (18025514) 4
US area of interest Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 7 2 2 1 2 0 0 0 0
References Study Quality
28 (19082589) 3
WBC scan area of interest Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 2 3 3 2 1 0 0 0
References Study Quality
17 (21934545) M
21 (28451827) 4
15 (30675635) 4
CT area of interest without and with IV contrast Usually not appropriate Limited Varies Varies 2 2 7 1 4 0 1 1 0 0 0
References Study Quality
11 (18025514) 4
Variant 4: Suspected osteomyelitis or soft tissue infection with implanted extra-articular surgical hardware. Initial radiographs normal or with findings suggestive of osteomyelitis or soft tissue infection with implanted extra-articular surgical hardware. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI area of interest without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 1 2 5 6
References Study Quality
27 (20180105) 3
32 (19255815) 4
31 (30683987) 4
21 (28451827) 4
MRI area of interest without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 5 0 5 3 1
References Study Quality
27 (20180105) 3
32 (19255815) 4
31 (30683987) 4
21 (28451827) 4
US area of interest May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 1 2 2 2 5 1 0 0 1
References Study Quality
33 (14749963) 4
28 (19082589) 3
3-phase bone scan and WBC scan area of interest May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 4 1 2 3 3 0 0 0 1
References Study Quality
21 (28451827) 4
FDG-PET/CT area of interest May be appropriate Limited ☢☢☢☢ 10-30 mSv 5 5 0 0 0 3 11 0 0 0 0
References Study Quality
30 (17136411) 3
22 (26547722) 2
21 (28451827) 4
WBC scan and sulfur colloid scan area of interest May be appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 0 1 7 6 0 0 0 0
WBC scan area of interest May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 0 2 7 5 0 0 0 0
References Study Quality
21 (28451827) 4
CT area of interest with IV contrast May be appropriate Limited Varies Varies 6 6 0 0 0 0 7 6 1 0 0
References Study Quality
29 (16759307) 3
22 (26547722) 2
21 (28451827) 4
CT area of interest without IV contrast May be appropriate Limited Varies Varies 5 5 0 0 1 0 13 0 0 0 0
References Study Quality
29 (16759307) 3
22 (26547722) 2
21 (28451827) 4
Image-guided aspiration area of interest Usually not appropriate Expert Consensus Varies Varies 1 1 9 2 3 0 0 0 0 0 0
3-phase bone scan area of interest Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 5 1 3 2 2 0 1 0 0
References Study Quality
19 (17146681) 3
17 (21934545) M
21 (28451827) 4
3-phase bone scan and WBC scan and sulfur colloid scan area of interest Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 8 1 2 1 0 1 0 1 0
CT area of interest without and with IV contrast Usually not appropriate Limited Varies Varies 1 1 8 3 3 0 0 0 0 0 0
References Study Quality
29 (16759307) 3
22 (26547722) 2
21 (28451827) 4
Variant 5: Suspected septic arthritis with arthroplasty or other implanted intra-articular surgical hardware. Initial radiographs normal or with findings suggestive of septic arthritis with arthroplasty or other implanted intra-articular surgical hardware. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Image-guided aspiration area of interest Usually appropriate Limited Varies Varies 9 9 0 0 1 1 0 0 0 2 10
References Study Quality
31 (30683987) 4
39 (28932957) 3
38 (31056444) 2
MRI area of interest without and with IV contrast Usually appropriate Moderate O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 2 2 7 3
References Study Quality
41 (14684523) 3
43 (19132424) 4
32 (19255815) 4
42 (31642691) 1
21 (28451827) 4
MRI area of interest without IV contrast Usually appropriate Moderate O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 3 1 6 4 0
References Study Quality
41 (14684523) 3
43 (19132424) 4
32 (19255815) 4
42 (31642691) 1
21 (28451827) 4
CT area of interest with IV contrast Usually appropriate Limited Varies Varies 7 7 0 0 1 0 3 3 5 2 0
References Study Quality
11 (18025514) 4
31 (30683987) 4
21 (28451827) 4
US area of interest May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 5 9 0 0 0 0
References Study Quality
33 (14749963) 4
28 (19082589) 3
3-phase bone scan and WBC scan area of interest May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 5 0 1 3 4 0 0 0 1
References Study Quality
34 (26706230) 3
FDG-PET/CT area of interest May be appropriate Limited ☢☢☢☢ 10-30 mSv 4 4 4 0 3 2 4 0 1 0 0
References Study Quality
36 (27707850) Inadequate
40 (31365498) 4
WBC scan and sulfur colloid scan area of interest May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 0 1 8 5 0 0 0 0
References Study Quality
36 (27707850) Inadequate
44 (28555449) 3
WBC scan area of interest May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 0 2 6 6 0 0 0 0
References Study Quality
45 (19958846) 4
34 (26706230) 3
36 (27707850) Inadequate
CT area of interest without IV contrast May be appropriate Limited Varies Varies 5 5 0 0 0 2 10 2 0 0 0
References Study Quality
11 (18025514) 4
31 (30683987) 4
21 (28451827) 4
3-phase bone scan area of interest Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 0 4 2 0 0 0 0 0
References Study Quality
34 (26706230) 3
36 (27707850) Inadequate
35 (28969761) 4
37 (30888518) 3
3-phase bone scan and WBC scan and sulfur colloid scan area of interest Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 7 2 0 2 1 1 0 1 0
CT area of interest without and with IV contrast Usually not appropriate Limited Varies Varies 1 1 10 3 1 0 0 0 0 0 0
References Study Quality
11 (18025514) 4
31 (30683987) 4
21 (28451827) 4
Variant 6: Suspected soft tissue infection. History of puncture wound with possible retained foreign body. Radiographs normal. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US area of interest Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 1 0 0 1 5 7
References Study Quality
47 (24951233) 4
46 (33136481) 4
48 (29426979) 2
MRI area of interest without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 3 2 5 3 1
References Study Quality
47 (24951233) 4
46 (33136481) 4
MRI area of interest without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 2 3 2 4 3 0
References Study Quality
47 (24951233) 4
46 (33136481) 4
CT area of interest with IV contrast Usually appropriate Limited Varies Varies 7 7 0 0 0 0 3 2 4 1 4
References Study Quality
47 (24951233) 4
46 (33136481) 4
CT area of interest without and with IV contrast Usually appropriate Limited Varies Varies 7 7 0 0 1 1 4 1 5 1 1
References Study Quality
47 (24951233) 4
46 (33136481) 4
CT area of interest without IV contrast Usually appropriate Limited Varies Varies 7 7 0 0 0 0 3 1 7 1 2
References Study Quality
47 (24951233) 4
46 (33136481) 4
Variant 7: Suspected soft tissue infection. Initial radiographs show soft tissue gas (without puncture wound) or are normal with high clinical suspicion of necrotizing fasciitis. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI area of interest without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 0 2 8 4
References Study Quality
50 (30887193) 2
49 (25539248) 4
52 (29537292) 4
2 (27726741) 4
54 (29672405) Good
56 (21406630) 3
57 (23043899) 4
58 (9490940) 3
MRI area of interest without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 0 7 4 3
References Study Quality
50 (30887193) 2
49 (25539248) 4
52 (29537292) 4
2 (27726741) 4
54 (29672405) Good
56 (21406630) 3
57 (23043899) 4
58 (9490940) 3
CT area of interest with IV contrast Usually appropriate Moderate Varies Varies 8 8 0 0 0 0 0 3 4 2 5
References Study Quality
6 (28366223) 4
51 (26286006) 3
49 (25539248) 4
52 (29537292) 4
2 (27726741) 4
54 (29672405) Good
53 (9169717) 4
55 (29211672) 4
CT area of interest without IV contrast Usually appropriate Moderate Varies Varies 9 9 0 0 0 0 0 1 3 3 7
References Study Quality
6 (28366223) 4
51 (26286006) 3
49 (25539248) 4
52 (29537292) 4
2 (27726741) 4
54 (29672405) Good
53 (9169717) 4
55 (29211672) 4
US area of interest May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 1 13 0 0 0 0
References Study Quality
60 (31031033) 3
52 (29537292) 4
57 (23043899) 4
59 (-3194804) 4
61 (24578776) 4
62 (21480291) 4
CT area of interest without and with IV contrast Usually not appropriate Moderate Varies Varies 1 1 12 1 1 0 0 0 0 0 0
References Study Quality
6 (28366223) 4
51 (26286006) 3
49 (25539248) 4
52 (29537292) 4
2 (27726741) 4
54 (29672405) Good
53 (9169717) 4
55 (29211672) 4
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.