Imaging After Shoulder Arthroplasty

Variant: 1 Routine follow-up of the asymptomatic patient with a primary shoulder arthroplasty.

Procedure	Appropriateness Category	Relative Radiation Level
Radiography shoulder	Usually Appropriate	☢
US shoulder	Usually Not Appropriate	O
MRI shoulder without and with IV contrast	Usually Not Appropriate	O
MRI shoulder without IV contrast	Usually Not Appropriate	O
3-phase bone scan with SPECT or SPECT/CT shoulder	Usually Not Appropriate	☢☢☢
Bone scan shoulder	Usually Not Appropriate	☢☢☢
CT shoulder with IV contrast	Usually Not Appropriate	☢☢☢
CT shoulder without and with IV contrast	Usually Not Appropriate	☢☢☢
CT shoulder without IV contrast	Usually Not Appropriate	☢☢☢
Fluoride PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 2 Symptomatic patient with a primary shoulder arthroplasty. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
Radiography shoulder	Usually Appropriate	☢
US shoulder	Usually Not Appropriate	O
MRI shoulder without and with IV contrast	Usually Not Appropriate	O
MRI shoulder without IV contrast	Usually Not Appropriate	O
3-phase bone scan with SPECT or SPECT/CT shoulder	Usually Not Appropriate	☢☢☢
Bone scan shoulder	Usually Not Appropriate	☢☢☢
CT shoulder with IV contrast	Usually Not Appropriate	☢☢☢
CT shoulder without and with IV contrast	Usually Not Appropriate	☢☢☢
CT shoulder without IV contrast	Usually Not Appropriate	☢☢☢
Fluoride PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 3 Symptomatic patient with a primary shoulder arthroplasty, infection not excluded. Additional imaging following radiographs.

Procedure	Appropriateness Category	Relative Radiation Level
Image-guided aspiration shoulder	Usually Appropriate	Varies
US shoulder	May Be Appropriate	O
MRI shoulder without and with IV contrast	May Be Appropriate	O
MRI shoulder without IV contrast	May Be Appropriate (Disagreement)	O
3-phase bone scan and WBC scan and sulfur colloid scan shoulder	May Be Appropriate	☢☢☢☢
3-phase bone scan and WBC scan and sulfur colloid scan with SPECT or SPECT/CT shoulder	May Be Appropriate	☢☢☢☢
WBC scan and sulfur colloid scan shoulder	May Be Appropriate (Disagreement)	☢☢☢☢
3-phase bone scan with SPECT or SPECT/CT shoulder	Usually Not Appropriate	☢☢☢
Bone scan shoulder	Usually Not Appropriate	☢☢☢
CT shoulder with IV contrast	Usually Not Appropriate	☢☢☢
CT shoulder without and with IV contrast	Usually Not Appropriate	☢☢☢
CT shoulder without IV contrast	Usually Not Appropriate	☢☢☢
Fluoride PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 4 Symptomatic patient with a primary shoulder arthroplasty, infection excluded. Suspected loosening. Additional imaging following radiographs.

Procedure	Appropriateness Category	Relative Radiation Level
MRI shoulder without IV contrast	Usually Appropriate	O
CT shoulder without IV contrast	Usually Appropriate	☢☢☢
US shoulder	May Be Appropriate (Disagreement)	O
3-phase bone scan with SPECT or SPECT/CT shoulder	May Be Appropriate	☢☢☢
MRI shoulder without and with IV contrast	Usually Not Appropriate	O
Bone scan shoulder	Usually Not Appropriate	☢☢☢
CT shoulder with IV contrast	Usually Not Appropriate	☢☢☢
CT shoulder without and with IV contrast	Usually Not Appropriate	☢☢☢
Fluoride PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

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	Relative Radiation Level
US shoulder	Usually Appropriate	O
MRI shoulder without IV contrast	Usually Appropriate	O
CT arthrography shoulder	Usually Appropriate	☢☢☢☢
MRI shoulder without and with IV contrast	Usually Not Appropriate	O
3-phase bone scan with SPECT or SPECT/CT shoulder	Usually Not Appropriate	☢☢☢
Bone scan shoulder	Usually Not Appropriate	☢☢☢
CT shoulder with IV contrast	Usually Not Appropriate	☢☢☢
CT shoulder without and with IV contrast	Usually Not Appropriate	☢☢☢
CT shoulder without IV contrast	Usually Not Appropriate	☢☢☢
Fluoride PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Panel Members

Catherine C. Roberts, MD^a; Darlene F. Metter, MD^b; Michael G. Fox, MD, MBA^c; Marc Appel, MD^d; Shari T. Jawetz, MD^e; William B. Morrison, MD^f; Nicholas C. Nacey, MD^g; Nicholas Said, MD, MBA^h; J. Derek Stensby, MDⁱ; Naveen Subhas, MD, MPH^j; Katherine M. Tynus, MD^k; Eric A. Walker, MD, MHA^l; Joseph S. Yu, MD^m; Mark J. Kransdorf, MDⁿ.

Summary of Literature Review

Introduction/Background

Special Imaging Considerations

Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

There are procedures that are equivalent alternatives (i.e., only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

There are complementary procedures (i.e., more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).

Discussion of Procedures by Variant

Variant 1: Routine follow-up of the asymptomatic patient with a primary shoulder arthroplasty.

Variant 1: Routine follow-up of the asymptomatic patient with a primary shoulder arthroplasty.
A. 3-phase bone scan with SPECT or SPECT/CT shoulder

Variant 1: Routine follow-up of the asymptomatic patient with a primary shoulder arthroplasty.
B. Bone scan shoulder

Variant 1: Routine follow-up of the asymptomatic patient with a primary shoulder arthroplasty.
C. CT shoulder

Variant 1: Routine follow-up of the asymptomatic patient with a primary shoulder arthroplasty.
D. Fluoride PET/CT skull base to mid-thigh

Variant 1: Routine follow-up of the asymptomatic patient with a primary shoulder arthroplasty.
E. MRI shoulder

Variant 1: Routine follow-up of the asymptomatic patient with a primary shoulder arthroplasty.
F. Radiography shoulder

Variant 1: Routine follow-up of the asymptomatic patient with a primary shoulder arthroplasty.
G. US shoulder

Variant 2: Symptomatic patient with a primary shoulder arthroplasty. Initial imaging.

Variant 2: Symptomatic patient with a primary shoulder arthroplasty. Initial imaging.
A. 3-phase bone scan with SPECT or SPECT/CT shoulder

Variant 2: Symptomatic patient with a primary shoulder arthroplasty. Initial imaging.
B. Bone scan shoulder

Variant 2: Symptomatic patient with a primary shoulder arthroplasty. Initial imaging.
C. CT shoulder

Variant 2: Symptomatic patient with a primary shoulder arthroplasty. Initial imaging.
D. Fluoride PET/CT skull base to mid-thigh

Variant 2: Symptomatic patient with a primary shoulder arthroplasty. Initial imaging.
E. MRI shoulder

Variant 2: Symptomatic patient with a primary shoulder arthroplasty. Initial imaging.
F. Radiography shoulder

Variant 2: Symptomatic patient with a primary shoulder arthroplasty. Initial imaging.
G. US shoulder

Variant 3: Symptomatic patient with a primary shoulder arthroplasty, infection not excluded. Additional imaging following radiographs.

Variant 3: Symptomatic patient with a primary shoulder arthroplasty, infection not excluded. Additional imaging following radiographs.
A. 3-phase bone scan and WBC scan and sulfur colloid scan shoulder

Variant 3: Symptomatic patient with a primary shoulder arthroplasty, infection not excluded. Additional imaging following radiographs.
B. 3-phase bone scan and WBC scan and sulfur colloid scan with SPECT or SPECT/CT shoulder

Variant 3: Symptomatic patient with a primary shoulder arthroplasty, infection not excluded. Additional imaging following radiographs.
C. 3-phase bone scan with SPECT or SPECT/CT shoulder

Variant 3: Symptomatic patient with a primary shoulder arthroplasty, infection not excluded. Additional imaging following radiographs.
D. Image-Guided Aspiration Shoulder

Variant 3: Symptomatic patient with a primary shoulder arthroplasty, infection not excluded. Additional imaging following radiographs.
E. Bone Scan Shoulder

Variant 3: Symptomatic patient with a primary shoulder arthroplasty, infection not excluded. Additional imaging following radiographs.
F. CT Shoulder

Variant 3: Symptomatic patient with a primary shoulder arthroplasty, infection not excluded. Additional imaging following radiographs.
G. Fluoride PET/CT skull base to mid-thigh

Variant 3: Symptomatic patient with a primary shoulder arthroplasty, infection not excluded. Additional imaging following radiographs.
H. MRI Shoulder

Variant 3: Symptomatic patient with a primary shoulder arthroplasty, infection not excluded. Additional imaging following radiographs.
I. US shoulder

Variant 3: Symptomatic patient with a primary shoulder arthroplasty, infection not excluded. Additional imaging following radiographs.
J. WBC scan and sulfur colloid scan shoulder

Variant 4: Symptomatic patient with a primary shoulder arthroplasty, infection excluded. Suspected loosening. Additional imaging following radiographs.

Variant 4: Symptomatic patient with a primary shoulder arthroplasty, infection excluded. Suspected loosening. Additional imaging following radiographs.
A. 3-phase bone scan with SPECT or SPECT/CT shoulder

Variant 4: Symptomatic patient with a primary shoulder arthroplasty, infection excluded. Suspected loosening. Additional imaging following radiographs.
B. Bone scan shoulder

Variant 4: Symptomatic patient with a primary shoulder arthroplasty, infection excluded. Suspected loosening. Additional imaging following radiographs.
C. CT shoulder

Variant 4: Symptomatic patient with a primary shoulder arthroplasty, infection excluded. Suspected loosening. Additional imaging following radiographs.
D. Fluoride PET/CT skull base to mid-thigh

Variant 4: Symptomatic patient with a primary shoulder arthroplasty, infection excluded. Suspected loosening. Additional imaging following radiographs.
E. MRI shoulder

Variant 4: Symptomatic patient with a primary shoulder arthroplasty, infection excluded. Suspected loosening. Additional imaging following radiographs.
F. US shoulder

Variant 5: Symptomatic patient with a primary shoulder arthroplasty, infection excluded. Suspected rotator cuff tear or other soft tissue abnormality. Additional imaging following radiographs.

Variant 5: Symptomatic patient with a primary shoulder arthroplasty, infection excluded. Suspected rotator cuff tear or other soft tissue abnormality. Additional imaging following radiographs.
A. 3-phase bone scan with SPECT or SPECT/CT shoulder

Summary of Recommendations

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”

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The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.