Imaging After Total Knee Arthroplasty

Variant: 1 Follow-up of symptomatic or asymptomatic patients with a total knee arthroplasty. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
Radiography knee	Usually Appropriate	☢
US knee	Usually Not Appropriate	O
Fluoroscopy knee	Usually Not Appropriate	☢
Image-guided aspiration knee	Usually Not Appropriate	Varies
MRI knee without and with IV contrast	Usually Not Appropriate	O
MRI knee without IV contrast	Usually Not Appropriate	O
CT arthrography knee	Usually Not Appropriate	☢
CT knee with IV contrast	Usually Not Appropriate	☢
CT knee without and with IV contrast	Usually Not Appropriate	☢
CT knee without IV contrast	Usually Not Appropriate	☢
3-phase bone scan knee	Usually Not Appropriate	☢☢☢
FDG-PET/CT whole body	Usually Not Appropriate	☢☢☢☢
Fluoride PET/CT whole body	Usually Not Appropriate	☢☢☢☢
WBC scan and sulfur colloid scan knee	Usually Not Appropriate	☢☢☢☢

Variant: 2 Suspected infection after total knee arthroplasty. Additional imaging following radiographs.

Procedure	Appropriateness Category	Relative Radiation Level
Image-guided aspiration knee	Usually Appropriate	Varies
US knee	May Be Appropriate	O
MRI knee without and with IV contrast	May Be Appropriate	O
MRI knee without IV contrast	May Be Appropriate	O
CT knee with IV contrast	May Be Appropriate	☢
3-phase bone scan knee	May Be Appropriate	☢☢☢
WBC scan and sulfur colloid scan knee	May Be Appropriate	☢☢☢☢
Fluoroscopy knee	Usually Not Appropriate	☢
CT arthrography knee	Usually Not Appropriate	☢
CT knee without and with IV contrast	Usually Not Appropriate	☢
CT knee without IV contrast	Usually Not Appropriate	☢
FDG-PET/CT whole body	Usually Not Appropriate	☢☢☢☢
Fluoride PET/CT whole body	Usually Not Appropriate	☢☢☢☢

Variant: 3 Pain after total knee arthroplasty. Infection excluded. Suspect aseptic loosening or osteolysis or instability. Additional imaging following radiographs.

Procedure	Appropriateness Category	Relative Radiation Level
MRI knee without IV contrast	Usually Appropriate	O
CT knee without IV contrast	Usually Appropriate	☢
3-phase bone scan knee	May Be Appropriate	☢☢☢
US knee	Usually Not Appropriate	O
Fluoroscopy knee	Usually Not Appropriate	☢
MRI knee without and with IV contrast	Usually Not Appropriate	O
CT arthrography knee	Usually Not Appropriate	☢
CT knee with IV contrast	Usually Not Appropriate	☢
CT knee without and with IV contrast	Usually Not Appropriate	☢
FDG-PET/CT whole body	Usually Not Appropriate	☢☢☢☢
Fluoride PET/CT whole body	Usually Not Appropriate	☢☢☢☢
WBC scan and sulfur colloid scan knee	Usually Not Appropriate	☢☢☢☢

Variant: 4 Pain after total knee arthroplasty. Suspect periprosthetic or hardware fracture. Additional imaging following radiographs.

Procedure	Appropriateness Category	Relative Radiation Level
CT knee without IV contrast	Usually Appropriate	☢
MRI knee without IV contrast	May Be Appropriate	O
3-phase bone scan knee	May Be Appropriate	☢☢☢
US knee	Usually Not Appropriate	O
Fluoroscopy knee	Usually Not Appropriate	☢
MRI knee without and with IV contrast	Usually Not Appropriate	O
CT arthrography knee	Usually Not Appropriate	☢
CT knee with IV contrast	Usually Not Appropriate	☢
CT knee without and with IV contrast	Usually Not Appropriate	☢
FDG-PET/CT whole body	Usually Not Appropriate	☢☢☢☢
Fluoride PET/CT whole body	Usually Not Appropriate	☢☢☢☢
WBC scan and sulfur colloid scan knee	Usually Not Appropriate	☢☢☢☢

Variant: 5 Pain after total knee arthroplasty. Measuring component rotation. Additional imaging following radiographs.

Procedure	Appropriateness Category	Relative Radiation Level
CT knee without IV contrast	Usually Appropriate	☢
MRI knee without IV contrast	May Be Appropriate	O
US knee	Usually Not Appropriate	O
Fluoroscopy knee	Usually Not Appropriate	☢
MRI knee without and with IV contrast	Usually Not Appropriate	O
CT arthrography knee	Usually Not Appropriate	☢
CT knee with IV contrast	Usually Not Appropriate	☢
CT knee without and with IV contrast	Usually Not Appropriate	☢
3-phase bone scan knee	Usually Not Appropriate	☢☢☢
FDG-PET/CT whole body	Usually Not Appropriate	☢☢☢☢
Fluoride PET/CT whole body	Usually Not Appropriate	☢☢☢☢
WBC scan and sulfur colloid scan knee	Usually Not Appropriate	☢☢☢☢

Variant: 6 Pain after total knee arthroplasty. Suspect periprosthetic soft-tissue abnormality unrelated to infection, including quadriceps or patellar tendinopathy (quadriceps or patellar tendon tears, postoperative arthrofibrosis, patellar clunk syndrome, or impingement of nerves or other soft tissues). Additional imaging following radiographs.

Procedure	Appropriateness Category	Relative Radiation Level
US knee	Usually Appropriate	O
MRI knee without IV contrast	Usually Appropriate	O
Fluoroscopy knee	Usually Not Appropriate	☢
MRI knee without and with IV contrast	Usually Not Appropriate	O
CT arthrography knee	Usually Not Appropriate	☢
CT knee with IV contrast	Usually Not Appropriate	☢
CT knee without and with IV contrast	Usually Not Appropriate	☢
CT knee without IV contrast	Usually Not Appropriate	☢
3-phase bone scan knee	Usually Not Appropriate	☢☢☢
FDG-PET/CT whole body	Usually Not Appropriate	☢☢☢☢
Fluoride PET/CT whole body	Usually Not Appropriate	☢☢☢☢
WBC scan and sulfur colloid scan knee	Usually Not Appropriate	☢☢☢☢

Panel Members

Eric A. Walker, MD, MHA^a; Michael G. Fox, MD^b; Donna G. Blankenbaker, MD^c; Cristy N. French, MD^d; Matthew A. Frick, MD^e; Tarek N. Hanna, MD^f; Shari T. Jawetz, MD^g; Cayce Onks, DO, MS^h; Nicholas Said, MD, MBAⁱ; J. Derek Stensby, MD^j; Francesca D. Beaman, MD^k.

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: Follow-up of symptomatic or asymptomatic patients with a total knee arthroplasty. Initial imaging.

Variant 1: Follow-up of symptomatic or asymptomatic patients with a total knee arthroplasty. Initial imaging.
A. 3-phase bone scan knee

Variant 1: Follow-up of symptomatic or asymptomatic patients with a total knee arthroplasty. Initial imaging.
B. CT arthrography knee

Variant 1: Follow-up of symptomatic or asymptomatic patients with a total knee arthroplasty. Initial imaging.
C. CT knee with IV contrast

Variant 1: Follow-up of symptomatic or asymptomatic patients with a total knee arthroplasty. Initial imaging.
D. CT knee without and with IV contrast

Variant 1: Follow-up of symptomatic or asymptomatic patients with a total knee arthroplasty. Initial imaging.
E. CT knee without IV contrast

Variant 1: Follow-up of symptomatic or asymptomatic patients with a total knee arthroplasty. Initial imaging.
F. FDG-PET/CT whole body

Variant 1: Follow-up of symptomatic or asymptomatic patients with a total knee arthroplasty. Initial imaging.
G. Fluoride PET/CT whole body

Variant 1: Follow-up of symptomatic or asymptomatic patients with a total knee arthroplasty. Initial imaging.
H. Fluoroscopy knee

Variant 1: Follow-up of symptomatic or asymptomatic patients with a total knee arthroplasty. Initial imaging.
I. Image-guided aspiration knee

Variant 1: Follow-up of symptomatic or asymptomatic patients with a total knee arthroplasty. Initial imaging.
J. MRI knee without and with IV contrast

Variant 1: Follow-up of symptomatic or asymptomatic patients with a total knee arthroplasty. Initial imaging.
K. MRI knee without IV contrast

Variant 1: Follow-up of symptomatic or asymptomatic patients with a total knee arthroplasty. Initial imaging.
L. Radiography knee

Variant 1: Follow-up of symptomatic or asymptomatic patients with a total knee arthroplasty. Initial imaging.
M. US knee

Variant 1: Follow-up of symptomatic or asymptomatic patients with a total knee arthroplasty. Initial imaging.
N. WBC scan and sulfur colloid scan knee

Variant 2: Suspected infection after total knee arthroplasty. Additional imaging following radiographs.

Variant 2: Suspected infection after total knee arthroplasty. Additional imaging following radiographs.
A. 3-phase bone scan knee

Variant 2: Suspected infection after total knee arthroplasty. Additional imaging following radiographs.
B. CT arthrography knee

Variant 2: Suspected infection after total knee arthroplasty. Additional imaging following radiographs.
C. CT knee with IV contrast

Variant 2: Suspected infection after total knee arthroplasty. Additional imaging following radiographs.
D. CT knee without and with IV contrast

Variant 2: Suspected infection after total knee arthroplasty. Additional imaging following radiographs.
E. CT knee without IV contrast

Variant 2: Suspected infection after total knee arthroplasty. Additional imaging following radiographs.
F. FDG-PET/CT whole body

Variant 2: Suspected infection after total knee arthroplasty. Additional imaging following radiographs.
G. Fluoride PET/CT whole body

Variant 2: Suspected infection after total knee arthroplasty. Additional imaging following radiographs.
H. Fluoroscopy knee

Variant 2: Suspected infection after total knee arthroplasty. Additional imaging following radiographs.
I. Image-guided aspiration knee

Variant 2: Suspected infection after total knee arthroplasty. Additional imaging following radiographs.
J. MRI knee without and with IV contrast

Variant 2: Suspected infection after total knee arthroplasty. Additional imaging following radiographs.
K. MRI knee without IV contrast

Variant 2: Suspected infection after total knee arthroplasty. Additional imaging following radiographs.
L. US knee

Variant 2: Suspected infection after total knee arthroplasty. Additional imaging following radiographs.
M. WBC scan and sulfur colloid scan knee

Variant 3: Pain after total knee arthroplasty. Infection excluded. Suspect aseptic loosening or osteolysis or instability. Additional imaging following radiographs.

Variant 3: Pain after total knee arthroplasty. Infection excluded. Suspect aseptic loosening or osteolysis or instability. Additional imaging following radiographs.
A. 3-phase bone scan knee

Variant 3: Pain after total knee arthroplasty. Infection excluded. Suspect aseptic loosening or osteolysis or instability. Additional imaging following radiographs.
B. CT arthrography knee

Variant 3: Pain after total knee arthroplasty. Infection excluded. Suspect aseptic loosening or osteolysis or instability. Additional imaging following radiographs.
C. CT knee with IV contrast

Variant 3: Pain after total knee arthroplasty. Infection excluded. Suspect aseptic loosening or osteolysis or instability. Additional imaging following radiographs.
F. FDG-PET/CT whole body

Variant 3: Pain after total knee arthroplasty. Infection excluded. Suspect aseptic loosening or osteolysis or instability. Additional imaging following radiographs.
H. Fluoroscopy knee

Variant 3: Pain after total knee arthroplasty. Infection excluded. Suspect aseptic loosening or osteolysis or instability. Additional imaging following radiographs.
K. US knee

Variant 4: Pain after total knee arthroplasty. Suspect periprosthetic or hardware fracture. Additional imaging following radiographs.

Variant 4: Pain after total knee arthroplasty. Suspect periprosthetic or hardware fracture. Additional imaging following radiographs.
A. 3-phase bone scan knee

Variant 4: Pain after total knee arthroplasty. Suspect periprosthetic or hardware fracture. Additional imaging following radiographs.
B. CT arthrography knee

Variant 4: Pain after total knee arthroplasty. Suspect periprosthetic or hardware fracture. Additional imaging following radiographs.
C. CT knee with IV contrast

Variant 4: Pain after total knee arthroplasty. Suspect periprosthetic or hardware fracture. Additional imaging following radiographs.
D. CT knee without and with IV contrast

Variant 4: Pain after total knee arthroplasty. Suspect periprosthetic or hardware fracture. Additional imaging following radiographs.
E. CT knee without IV contrast

Variant 4: Pain after total knee arthroplasty. Suspect periprosthetic or hardware fracture. Additional imaging following radiographs.
F. FDG-PET/CT whole body

Variant 4: Pain after total knee arthroplasty. Suspect periprosthetic or hardware fracture. Additional imaging following radiographs.
G. Fluoride PET/CT whole body

Variant 4: Pain after total knee arthroplasty. Suspect periprosthetic or hardware fracture. Additional imaging following radiographs.
H. Fluoroscopy knee

Variant 4: Pain after total knee arthroplasty. Suspect periprosthetic or hardware fracture. Additional imaging following radiographs.
I. MRI knee without and with IV contrast

Variant 4: Pain after total knee arthroplasty. Suspect periprosthetic or hardware fracture. Additional imaging following radiographs.
J. MRI knee without IV contrast

Variant 4: Pain after total knee arthroplasty. Suspect periprosthetic or hardware fracture. Additional imaging following radiographs.
K. US knee

Variant 4: Pain after total knee arthroplasty. Suspect periprosthetic or hardware fracture. Additional imaging following radiographs.
L. WBC scan and sulfur colloid scan knee

Variant 5: Pain after total knee arthroplasty. Measuring component rotation. Additional imaging following radiographs.

Variant 5: Pain after total knee arthroplasty. Measuring component rotation. Additional imaging following radiographs.
A. 3-phase bone scan knee

Variant 5: Pain after total knee arthroplasty. Measuring component rotation. Additional imaging following radiographs.
B. CT arthrography knee

Variant 5: Pain after total knee arthroplasty. Measuring component rotation. Additional imaging following radiographs.
C. CT knee with IV contrast

Variant 5: Pain after total knee arthroplasty. Measuring component rotation. Additional imaging following radiographs.
D. CT knee without and with IV contrast

Variant 5: Pain after total knee arthroplasty. Measuring component rotation. Additional imaging following radiographs.
E. CT knee without IV contrast

Variant 5: Pain after total knee arthroplasty. Measuring component rotation. Additional imaging following radiographs.
F. FDG-PET/CT whole body

Variant 5: Pain after total knee arthroplasty. Measuring component rotation. Additional imaging following radiographs.
G. Fluoride PET/CT whole body

Variant 5: Pain after total knee arthroplasty. Measuring component rotation. Additional imaging following radiographs.
H. Fluoroscopy knee

Variant 5: Pain after total knee arthroplasty. Measuring component rotation. Additional imaging following radiographs.
I. MRI knee without and with IV contrast

Variant 5: Pain after total knee arthroplasty. Measuring component rotation. Additional imaging following radiographs.
J. MRI knee without IV contrast

Variant 5: Pain after total knee arthroplasty. Measuring component rotation. Additional imaging following radiographs.
K. US knee

Variant 5: Pain after total knee arthroplasty. Measuring component rotation. Additional imaging following radiographs.
L. WBC scan and sulfur colloid scan knee

Variant 6: Pain after total knee arthroplasty. Suspect periprosthetic soft-tissue abnormality unrelated to infection, including quadriceps or patellar tendinopathy (quadriceps or patellar tendon tears, postoperative arthrofibrosis, patellar clunk syndrome, or impingement of nerves or other soft tissues). Additional imaging following radiographs.

Summary of Highlights

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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Disclaimer

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.