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Appropriateness Criteria

Variant 1: Routine follow-up of the asymptomatic patient with a primary shoulder arthroplasty.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography shoulder Usually appropriate Limited ☢ <0.1 mSv 9 9 0 0 0 0 0 0 1 0 10
References Study Quality
10 (24618199) 4
13 (22309766) 4
14 (22930212) 3
18 (23473606) 2
16 (30473242) 4
15 (28131693) 4
17 (28111179) 3
US shoulder Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 0 0 0 0 0 0 0 0
MRI shoulder without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 0 0 0 0 0 0 0 0
MRI shoulder without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 0 0 0 0 0 0 0 0
3-phase bone scan with SPECT or SPECT/CT shoulder Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 1 0 0 0 0 0 0 0
References Study Quality
12 (26652693) 4
Bone scan shoulder Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 11 0 0 0 0 0 0 0 0
CT shoulder with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 11 0 0 0 0 0 0 0 0
CT shoulder without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 11 0 0 0 0 0 0 0 0
CT shoulder without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 10 0 0 0 1 0 0 0 0
Fluoride PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 11 0 0 0 0 0 0 0 0
Variant 2: Symptomatic patient with a primary shoulder arthroplasty. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography shoulder Usually appropriate Limited ☢ <0.1 mSv 9 9 0 0 0 0 0 0 0 0 14
References Study Quality
10 (24618199) 4
13 (22309766) 4
24 (30241984) 4
US shoulder Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 12 1 0 1 0 0 0 0 0
References Study Quality
25 (1515896) 4
MRI shoulder without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
MRI shoulder without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 1 0 0 0 0 0 0 0
3-phase bone scan with SPECT or SPECT/CT shoulder Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 1 0 0 0 0 0 0 0
References Study Quality
34 (19605662) 4
Bone scan shoulder Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 14 0 0 0 0 0 0 0 0
References Study Quality
21 (19038601) 4
22 (536788) 4
CT shoulder with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 14 0 0 0 0 0 0 0 0
References Study Quality
23 (20036583) 4
CT shoulder without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 14 0 0 0 0 0 0 0 0
References Study Quality
23 (20036583) 4
CT shoulder without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 12 1 1 0 0 0 0 0 0
References Study Quality
23 (20036583) 4
Fluoride PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 14 0 0 0 0 0 0 0 0
Variant 3: Symptomatic patient with a primary shoulder arthroplasty, infection not excluded. Additional imaging following radiographs.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Image-guided aspiration shoulder Usually appropriate Limited Varies Varies 9 9 0 0 0 0 0 0 0 0 14
References Study Quality
35 (24293800) 4
34 (19605662) 4
36 (31563506) 3
US shoulder May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 1 1 8 2 2 0 0
References Study Quality
41 (12646465) 4
40 (12720010) 4
42 (23971477) 4
MRI shoulder without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 1 0 0 1 5 3 2 0 2
References Study Quality
37 (21862766) 3
39 (12195247) 3
28 (19884021) 4
38 (25264437) 4
MRI shoulder without IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 5 1 0 2 2 1 1 1 1
References Study Quality
37 (21862766) 3
39 (12195247) 3
28 (19884021) 4
38 (25264437) 4
3-phase bone scan and WBC scan and sulfur colloid scan shoulder May be appropriate Limited ☢☢☢☢ 10-30 mSv 5 5 2 0 0 4 7 0 1 0 0
References Study Quality
21 (19038601) 4
11 (16702459) 4
22 (536788) 4
30 (30193652) 4
3-phase bone scan and WBC scan and sulfur colloid scan with SPECT or SPECT/CT shoulder May be appropriate Limited ☢☢☢☢ 10-30 mSv 5 5 0 0 1 0 7 3 1 1 0
References Study Quality
21 (19038601) 4
11 (16702459) 4
22 (536788) 4
30 (30193652) 4
33 (32657859) 4
31 (33289359) 2
32 (33361187) 3
WBC scan and sulfur colloid scan shoulder May be appropriate (Disagreement) Expert Opinion ☢☢☢☢ 10-30 mSv 5 5 2 0 0 0 8 3 1 0 0
References Study Quality
41 (12646465) 4
40 (12720010) 4
42 (23971477) 4
3-phase bone scan with SPECT or SPECT/CT shoulder Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 4 1 5 3 1 0 0 0 0
References Study Quality
21 (19038601) 4
22 (536788) 4
30 (30193652) 4
20 (-3194396) 3
Bone scan shoulder Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 6 1 3 4 0 0 0 0 0
References Study Quality
21 (19038601) 4
22 (536788) 4
30 (30193652) 4
CT shoulder with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 7 0 0 3 4 0 0 0 0
References Study Quality
3 (17015609) 4
CT shoulder without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 12 2 0 0 0 0 0 0 0
References Study Quality
3 (17015609) 4
CT shoulder without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 8 1 1 2 2 0 0 0 0
References Study Quality
3 (17015609) 4
Fluoride PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 14 0 0 0 0 0 0 0 0
Variant 4: Symptomatic patient with a primary shoulder arthroplasty, infection excluded. Suspected loosening. Additional imaging following radiographs.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI shoulder without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 0 3 7 3
References Study Quality
37 (21862766) 3
39 (12195247) 3
58 (16829248) 4
38 (25264437) 4
CT shoulder without IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv 8 8 0 0 0 0 0 0 2 9 3
References Study Quality
50 (23479714) 4
10 (24618199) 4
47 (24286563) 3
55 (23412251) 4
53 (20551186) 1
57 (26234665) 3
54 (28561262) 4
49 (29426742) 4
51 (28796543) 2
52 (27186794) 2
56 (25922110) 2
48 (32364883) 4
US shoulder May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 5 0 1 1 4 3 0 0 0
References Study Quality
10 (24618199) 4
3-phase bone scan with SPECT or SPECT/CT shoulder May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 5 1 7 1 0 0 0
References Study Quality
21 (19038601) 4
22 (536788) 4
30 (30193652) 4
20 (-3194396) 3
MRI shoulder without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 12 0 0 0 2 0 0 0 0
References Study Quality
37 (21862766) 3
39 (12195247) 3
58 (16829248) 4
38 (25264437) 4
Bone scan shoulder Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 3 1 5 1 2 2 0 0 0
References Study Quality
21 (19038601) 4
30 (30193652) 4
CT shoulder with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv 1 1 13 1 0 0 0 0 0 0 0
References Study Quality
50 (23479714) 4
10 (24618199) 4
47 (24286563) 3
55 (23412251) 4
53 (20551186) 1
57 (26234665) 3
54 (28561262) 4
49 (29426742) 4
51 (28796543) 2
52 (27186794) 2
56 (25922110) 2
48 (32364883) 4
CT shoulder without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv 1 1 13 1 0 0 0 0 0 0 0
References Study Quality
50 (23479714) 4
10 (24618199) 4
47 (24286563) 3
55 (23412251) 4
53 (20551186) 1
57 (26234665) 3
54 (28561262) 4
49 (29426742) 4
51 (28796543) 2
52 (27186794) 2
56 (25922110) 2
48 (32364883) 4
Fluoride PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 14 0 0 0 0 0 0 0 0
Variant 5: Symptomatic patient with a primary shoulder arthroplasty, infection excluded. Suspected rotator cuff tear or other soft tissue abnormality. Additional imaging following radiographs.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US shoulder Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 1 0 0 0 1 0 2 10
References Study Quality
41 (12646465) 4
63 (16979047) 3
64 (29396098) 4
MRI shoulder without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 1 1 1 4 7
References Study Quality
37 (21862766) 3
10 (24618199) 4
39 (12195247) 3
58 (16829248) 4
63 (16979047) 3
38 (25264437) 4
CT arthrography shoulder Usually appropriate Limited ☢☢☢☢ 10-30 mSv 7 7 1 0 0 0 4 2 4 3 0
References Study Quality
10 (24618199) 4
59 (3715028) 4
61 (15829828) 3
60 (8020238) 4
MRI shoulder without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 11 0 1 0 0 1 0 1 0
References Study Quality
37 (21862766) 3
10 (24618199) 4
39 (12195247) 3
58 (16829248) 4
63 (16979047) 3
38 (25264437) 4
3-phase bone scan with SPECT or SPECT/CT shoulder Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 0 0 0 0 0 0 1 0
Bone scan shoulder Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 0 0 0 0 0 0 1 0
CT shoulder with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 12 0 1 0 0 1 0 0 0
References Study Quality
62 (30268356) 3
CT shoulder without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 13 1 0 0 0 0 0 0 0
References Study Quality
62 (30268356) 3
CT shoulder without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 9 3 0 1 0 0 0 0 0
References Study Quality
62 (30268356) 3
Fluoride PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 13 1 0 0 0 0 0 0 0
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.