Imaging Recommendations by EULAR for Symptomatic Osteoarthritis

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Conventional radiography, magnetic resonance imaging, ultrasonography, computed tomography, and nuclear medicine were the modalities examined.
Conventional radiography, magnetic resonance imaging, ultrasonography, computed tomography, and nuclear medicine were the modalities examined.

The first evidence-based recommendations on the use of imaging in osteoarthritis (OA) clinical practice have been released by the European League Against Rheumatism (EULAR) and published in the Annals of Rheumatic Diseases.1

"The role of imaging in clinical practice for OA diagnosis, management and follow-up has not been clearly defined," wrote the task force responsible for the recommendations.

"Despite this limitation, the increased availability of modern imaging has expanded its use, with possible excesses leading to increased costs. A [EULAR] task force was therefore created to develop evidence-based recommendations on the use of imaging in the management of symptomatic, peripheral joint OA, for clinicians who treat OA in their clinical practice."

The basis for the task force's recommendations was a systematic literature review of published studies on the role of imaging in the diagnosis, management, and follow-up of adults older than 18 years with symptomatic osteoarthritis of the knee, hip, hand, or foot.

Conventional radiography, magnetic resonance imaging, ultrasonography, computed tomography, and nuclear medicine were the modalities examined.

Led by Garifallia Sakellariou, MD, from the University of Pavia in Italy, the task force presented several overarching principles as background statements, beginning with the statement that the recommendations are pertinent only to symptomatic OA.

The overarching principles also counsel that both imaging abnormalities of OA and joint symptoms are common, especially in the aging patient, and that symptoms do not always correlate with imaging abnormalities; that full history and examination should precede investigations such as imaging; and that although imaging can detect a wide range of pathology in OA, the information it provides has yet to affect clinical decision-making.

Summary & Clinical Applicability

The task force made 7 evidence-based recommendations:

  1. "Imaging is not required to make the diagnosis in patients with typical presentation of OA." The authors noted that 1 study successfully demonstrated the value of ultrasound in the diagnosis of hand and feet arthritis; however, there was a lack of strong evidence for the use of other imaging modalities at other anatomical sites for diagnostic purposes.
  2. "In atypical presentations, imaging is recommended to help confirm the diagnosis of OA and/or make alternative or additional diagnoses." The value of this recommendation was not demonstrated by the literature; instead, its inclusion was based on expert opinion.
  3. "Routine imaging in OA follow-up is not recommended. However, imaging is recommended if there is unexpected rapid progression of symptoms or change in clinical characteristics to determine if this relates to OA severity or an additional diagnosis."
  4. "If imaging is needed, conventional (plain) radiography should be used before other modalities. To make additional diagnoses, soft tissues are best imaged by [ultrasound] or [magnetic resonance imaging,] and bone by [computed tomography] or [magnetic resonance imaging]." The task force chose to emphasize the use of conventional radiography, the most readily available and economical imaging modality, because most studies uncovered by the literature review involved its use, whereas none addressed the cost-effectiveness or sequencing of the other modalities.
  5. "Consideration of radiographic views is important for optimising detection of OA features; in particular for the knee, weightbearing and patellofemoral views are recommended."
  6. "According to current evidence, imaging features do not predict non-surgical treatment response and imaging cannot be recommended for this purpose."
  7. "The accuracy of intra-articular injection depends on the joint and on the skills of the practitioner and imaging may improve accuracy. Imaging is particularly recommended for joints that are difficult to access due to factors including site (eg, hip), degree of deformity and obesity."

The authors commented that although their recommendation does not stipulate a particular imaging modality, the use of ultrasound in the described scenario has a strong evidence base.

 

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Reference

  1. Sakellariou G, Conaghan PG, Zhang W, et al. EULAR recommendations for the use of imaging in the clinical management of peripheral joint osteoarthritis [published online April 7, 2017]. Ann Rheum Dis. doi: 10.1136/annrheumdis-2016-210815
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