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Appropriateness Criteria

Variant 1: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography knee Usually appropriate Moderate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 9 0 0 0 0 0 0 0 0 16
References Study Quality
10 (24751528) 4
11 (26797169) 4
12 (23118113) 2
13 (22438445) 3
US knee Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 1 1 0 2 0 0 0 0
Radiography hip ipsilateral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 11 0 1 1 2 0 1 0 0
Image-guided aspiration knee Usually not appropriate Expert Consensus Varies Varies 1 1 14 0 1 1 0 0 0 0 0
MR arthrography knee Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 1 0 0 1 0 0 0 0
MRI knee without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 0 2 0 0 0 1 0 0
References Study Quality
2 (25086957) 4
MRI knee without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 11 0 2 2 0 0 0 1 0
References Study Quality
2 (25086957) 4
CT arthrography knee Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 15 0 0 0 1 0 0 0 0
CT knee with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 15 0 0 0 1 0 0 0 0
CT knee without and with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 15 0 0 0 1 0 0 0 0
CT knee without IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 11 1 1 2 0 1 0 0 0
Bone scan knee Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 2 1 0 0 0 0 0 0
Variant 2: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial knee radiograph negative or demonstrates joint effusion. Next imaging procedure.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI knee without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 2 4 10
References Study Quality
21 (18784100) 4
28 (28473086) 4
11 (26797169) 4
13 (22438445) 3
15 (25442030) 4
17 (21647860) 2
18 (23321609) 4
19 (22736267) 2
20 (22012846) 4
22 (25022807) 2
23 (24020939) 2
24 (23377800) 2
25 (20829200) 4
26 (21360498) 2
27 (26290325) 3
29 (23845401) 3
30 (24583066) 2
31 (25724258) 3
32 (22421281) 2
33 (21969432) 4
34 (24651059) 4
35 (23982988) 2
36 (22184170) 4
37 (20418103) 4
38 (24119160) 2
39 (21618936) 4
40 (22862803) 4
41 (23478924) 4
42 (20884045) 4
43 (22488011) 4
44 (22134205) 4
45 (26242763) 2
US knee May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 1 1 1 8 2 2 1 0
References Study Quality
10 (24751528) 4
17 (21647860) 2
37 (20418103) 4
44 (22134205) 4
49 (22996306) 2
Radiography hip ipsilateral May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 2 1 0 2 10 1 1 0 0
References Study Quality
14 (23781753) 4
Radiography lumbar spine May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 3 1 0 1 11 0 1 0 0
Image-guided aspiration knee May be appropriate Limited Varies Varies 5 5 1 0 0 1 12 3 0 0 0
References Study Quality
10 (24751528) 4
MR arthrography knee May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 6 0 2 6 3 0 0 0 0
References Study Quality
10 (24751528) 4
CT arthrography knee May be appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 1 0 0 3 5 5 1 1 0
References Study Quality
16 (22447237) 4
CT knee without IV contrast May be appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 0 1 0 1 11 4 0 0 0
References Study Quality
15 (25442030) 4
MRI knee without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 8 1 1 2 2 1 1 0 0
References Study Quality
15 (25442030) 4
17 (21647860) 2
42 (20884045) 4
46 (23277189) 2
47 (21187293) 2
48 (25278070) 2
CT knee with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 13 1 0 1 1 0 0 0 0
References Study Quality
15 (25442030) 4
CT knee without and with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 12 1 0 2 1 0 0 0 0
References Study Quality
15 (25442030) 4
Bone scan knee Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 12 3 0 0 1 0 0 0 0
Variant 3: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial knee radiograph demonstrates osteochondritis dissecans (OCD), loose bodies, or history of cartilage or meniscal repair. Next imaging procedure.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI knee without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 3 1 12
References Study Quality
50 (18552309) 3
41 (23478924) 4
51 (24856089) 2
52 (21327672) 2
53 (24685525) 2
54 (24048551) 1
MR arthrography knee May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 3 0 0 2 7 4 1 0 0
References Study Quality
10 (24751528) 4
16 (22447237) 4
CT arthrography knee May be appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 6 6 1 0 0 1 4 3 5 2 0
References Study Quality
16 (22447237) 4
CT knee without IV contrast May be appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 0 0 1 1 11 4 0 0 0
US knee Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 8 0 0 1 1 0 0 0
Radiography hip ipsilateral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 12 2 1 1 0 0 0 0 0
Image-guided aspiration knee Usually not appropriate Expert Consensus Varies Varies 1 1 13 1 0 2 0 0 0 0 0
MRI knee without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 11 2 0 1 1 1 0 0 0
References Study Quality
16 (22447237) 4
CT knee with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 11 3 0 2 0 0 0 0 0
CT knee without and with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 13 1 1 1 0 0 0 0 0
Bone scan knee Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 2 0 0 0 0 0 0 0
Variant 4: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial knee radiograph demonstrates degenerative changes or chondrocalcinosis. Next imaging procedure.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Image-guided aspiration knee May be appropriate (Disagreement) Expert Opinion Varies Varies 5 5 3 1 0 2 7 4 0 0 0
References Study Quality
61 (26116548) 2
MRI knee without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 1 0 0 1 1 6 2 3 2
References Study Quality
58 (20360517) 3
10 (24751528) 4
11 (26797169) 4
18 (23321609) 4
19 (22736267) 2
55 (26316262) 3
56 (24418678) 2
57 (25746322) 2
59 (24821663) 3
CT knee without IV contrast May be appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 4 4 5 1 2 1 7 1 0 0 0
US knee Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 7 2 0 3 5 0 0 0 0
References Study Quality
11 (26797169) 4
60 (25691769) 1
Radiography hip ipsilateral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 12 1 1 0 2 0 0 0 0
MR arthrography knee Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 1 0 0 1 1 0 0 0
MRI knee without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 8 1 1 2 2 1 1 0 0
References Study Quality
58 (20360517) 3
10 (24751528) 4
11 (26797169) 4
18 (23321609) 4
19 (22736267) 2
55 (26316262) 3
56 (24418678) 2
57 (25746322) 2
59 (24821663) 3
CT arthrography knee Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 10 0 0 3 3 0 1 0 0
References Study Quality
11 (26797169) 4
CT knee with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 12 1 2 1 0 0 0 0 0
CT knee without and with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 12 1 1 2 0 0 0 0 0
Bone scan knee Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 10 2 2 1 1 0 0 0 0
References Study Quality
11 (26797169) 4
Variant 5: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial knee radiograph demonstrates signs of prior osseous injury (ie, Segond fracture, tibial spine avulsion, etc.). Next imaging procedure.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI knee without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 2 2 3 9
References Study Quality
41 (23478924) 4
65 (20978758) 2
CT arthrography knee May be appropriate Strong ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 0 0 0 2 7 5 2 1 0
References Study Quality
63 (11997545) 2
16 (22447237) 4
62 (18329214) 2
64 (10966722) 2
CT knee without IV contrast May be appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 0 0 0 2 13 2 0 0 0
References Study Quality
15 (25442030) 4
US knee Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 2 1 1 0 0 0 0 0
Radiography hip ipsilateral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 12 2 0 0 1 0 0 1 0
Image-guided aspiration knee Usually not appropriate Expert Consensus Varies Varies 1 1 14 0 1 1 0 0 0 0 0
MR arthrography knee Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 1 1 1 0 1 1 0 0
MRI knee without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 12 1 1 0 2 0 0 0 0
References Study Quality
41 (23478924) 4
65 (20978758) 2
CT knee with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 13 1 0 1 0 1 0 0 0
References Study Quality
15 (25442030) 4
CT knee without and with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 13 1 0 1 0 1 0 0 0
References Study Quality
15 (25442030) 4
Bone scan knee Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 1 1 0 0 1 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.