Comparison of knee magnetic resonance imaging findings in patients referred by orthopaedic surgeons versus nonorthopaedic practitioners

An automated, web-based triage tool may optimise referral pathways in elective orthopaedic surgery: A proof-of-concept study

Introduction

Knee pain is caused by various pathologies, making evaluation in primary-care challenging. Subsequently, an over-reliance on imaging, such as radiographs and MRI exists. Electronic-triage tools represent an innovative solution to this problem. The aims of this study were to establish the magnitude of unnecessary knee imaging prior to orthopaedic surgeon referral, and ascertain whether an e-triage tool outperforms existing clinical pathways to recommend correct imaging.

Methods

Patients ≥18 years presenting with knee pain treated with arthroscopy or arthroplasty at a single academic hospital between 2015 and 2020 were retrospectively identified. The timing and appropriateness of imaging were assessed according to national guidelines, and classified as 'necessary', 'unnecessary' or 'required MRI'. Based on an eDelphi consensus study, a symptom-based e-triage tool was developed and piloted to preliminarily diagnose five common knee pathologies and suggest appropriate imaging.

Results

1462 patients were identified. 17.2% (n = 132) of arthroplasty patients received an 'unnecessary MRI', 27.6% (n = 192) of arthroscopy patients did not have a 'necessary MRI', requiring follow-up. Forty-one patients trialled the e-triage pilot (mean age: 58.4 years, 58.5% female). Preliminary diagnoses were available for 33 patients. The e-triage tool correctly identified three of the four knee pathologies (one pathology did not present). 79.2% (n = 19) of participants would use the tool again.

Conclusion

A substantial number of knee pain patients receive incorrect imaging, incurring delays and unnecessary costs. A symptom-based e-triage tool was developed, with promising performance and user feedback. With refinement using larger datasets, this tool has the potential to improve wait-times, referral quality and reduce cost.

Magnetic Resonance Imaging for Elbow Pathology: Overused by Both Orthopaedic Surgeons and Primary Care Providers

Background

Magnetic resonance imaging (MRI) use by both orthopedic surgeons and primary care providers (PCP) for analysis of elbow pathology is expensive and growing in frequency. In light of this, scrutiny regarding the appropriate utilization of this technology is increasing. Currently, there is no literature investigating the appropriateness of MRI use for complex elbow pathology from either orthopedic surgeons or PCPs.

Methods

A retrospective chart review was performed on consecutive elbow MRIs performed at a tertiary care center between January 1, 2012, and December 31, 2015. A total of 225 patients were included. Patients meeting the inclusion criteria were divided into two cohorts, determined by whether the ordering provider was an orthopedic surgeon or a PCP. MRI referrals were made by orthopedic surgeons in 94 patients and by nonorthopedic surgery providers in 131 patients. MRI diagnoses of no pathology, muscle/tendon tear, neuritis/nerve injury, tendinosis, ligament injury/instability, osteoarthritis/degenerative joint disease/decreased range of motion/contracture, or fracture/osteochondral injury were analyzed, as were the interventions of no intervention, nonprocedural treatment (therapy, orthosis, or nonoperative modality), nonsurgical procedure/referral for procedure, referral to surgeon, surgery, additional imaging/electrodiagnostic nerve testing, or other.

Results

1. Orthopedic surgeons are more accurate in their diagnoses after MRI, while PCPs order more MRI scans for ‘routine’ diagnoses typically made without MRI. 2. When the MRI did not validate an orthopedic surgeon’s preimaging diagnosis, rates of surgery decreased. The same discrepancy in diagnosis leads to an increase in orthopedic surgeon referrals within the PCP cohort. 3. An MRI was ordered for “pain” by orthopedic surgeons and PCPs in approximately 30% of the patients in both groups with a similarly low rate of pathology discovery.

Conclusions

The unexpected result of this study is that there is still a large quantity of MRI exams being conducted by orthopedic surgeons for the preMRI diagnosis of “pain.” In both groups, there was a similar rate of negative imaging. We expected orthopedic surgeons who have advanced knowledge in musculoskeletal pathology would be less likely to order an MRI for pain and would also less likely order an MRI that resulted in no pathology. This places an increased and unnecessary burden on the financial aspect of the health care system.

Incidence Rates of Surgery After Knee MRI: Association According to Referring Physician Type and Patient's Age and Sex

Background

The utility of magnetic resonance imaging (MRI) in the primary care setting is uncertain, with a perception that there is less likelihood for surgery after MRI ordered by general practitioners (GPs) when compared with orthopaedic surgeons and sports medicine physicians. Additionally, the influence of patient age and sex on subsequent surgical intervention is currently unknown.

Purpose/Hypothesis

The purpose of this study was to compare surgical incidence after MRI referrals by orthopaedic surgeons, GPs, and sports medicine physicians, including a subset analysis for GP patients based on type of approval given by the radiologist. The authors also wanted to explore the association of age and sex on subsequent surgical intervention. They hypothesized that surgical incidence after MRI ordered by orthopaedic surgeons and sports medicine physicians would be higher than after MRI ordered by GPs.

Study Design

Cohort study; Level of evidence, 3.

Methods

Knee MRI referrals by the 3 physician cohorts during May to December 2017 were assessed. For GP patients, the types of approval or recommendation from a radiologist were categorized. Subsequent surgical intervention status was then compared among referral groups up to 2 years after MRI. Associations of age and sex with surgical occurrence were also assessed. Chi-square test, analysis of variance, and univariate/multivariable logistic regression were used for statistical analysis.

Results

Overall, 407 referrals were evaluated (GP, n = 173; orthopaedic, n = 176; sports medicine, n = 58). Surgical incidence was not significantly higher for orthopaedic and sports medicine than GP referrals at 3 months (10%, 3%, and 6%, respectively; P = .23), 6 months (20%, 17%, and 15%; P = .49), and 2 years (30%, 35%, and 24%; P = .25). Surgical incidence for GP patients was higher after discussion with a radiologist or when evaluating specific pathology on prior imaging versus less defined reasons (30.4% vs 15.7%, respectively; P = .03). Surgical incidence was lower for older patients (11% vs 31% for >60 years vs all other age groups combined; P = .002), and women were less likely to undergo surgery than men (22% vs 35%, respectively; P = .008).

Conclusion

Surgical incidence after MRI was likely appropriately lower for older patients. Lower incidence for female patients is of uncertain cause and warrants further study.

The use of magnetic resonance imaging (MRI) of the knee in current clinical practice: A retrospective evaluation of the MRI reports within a large NHS trust

BACKGROUND

Magnetic resonance imaging (MRI) is one of the most widely used investigations for knee pain as it provides detailed assessment of the bone and soft tissues. The aim of this study is to report the frequency of each diagnosis identified on MRI scans of the knee and explore the relationship between MRI results and onward treatment.

METHODS

Consecutive MRI reports from a large NHS trust performed in 2017 were included in this study. The hospital electronic system was consulted to identify whether a patient underwent x-ray prior to the MRI, attended an outpatient appointment or underwent surgery.

RESULTS

4466 MRI knees were performed in 2017 with 71.2% requested in primary care and 28.1% requested in secondary care. The most common diagnosis was signs of arthritis (55.2%), followed by meniscal tears (42.8%) and ACL tears (8.3%). 49.4% of patients who had an MRI attended outpatients and 15.6% underwent surgery. The rate of knee surgery was significantly higher for patients who had their scans requested in secondary care (32.9% vs 8.9%, p < 0.001).

CONCLUSION

The rate of surgical intervention following MRI is low and given these results it seems unlikely that the scan changes practice in most cases. The rate of surgery and outpatient follow up was significantly higher in scans requested by secondary care. We urge clinicians avoid wasteful use of MRI and recommend the use of plain radiography prior to MRI where arthritis may be present.

Post-traumatic knee MRI findings and associations with patient, trauma, and clinical characteristics: a subgroup analysis in primary care in the Netherlands

BACKGROUND

The added value of magnetic resonance imaging (MRI) in primary care is still being debated. A high diagnostic yield can be expected in young and active patients with post-traumatic knee complaints.

AIM

To determine the frequency of MRI abnormalities in young and active patients (aged 18-45 years) and the associations with patient, trauma, and clinical characteristics.

DESIGN AND SETTING

A subgroup analysis of 174 patients, aged 18-45 years with knee trauma of <6 months, allocated to MRI in a randomised controlled trial on the yield of MRI in primary care. Patients were recruited by 150 GPs in the Netherlands from October 2012 to November 2015.

METHOD

Associations were expressed using mean differences, odds ratio (OR) and predictive values.

RESULTS

Sixty-seven out of 174 patients (39%) had a positive MRI finding, predominantly anterior cruciate ligament (ACL) ruptures (22%) and/or traumatic meniscal tears (15%). Patients with a pre-existing musculoskeletal comorbidity had a two-fold lower prevalence of positive MRI findings (21%), OR 3.0 (95% confidence interval [CI] = 1.3 to 7.0). A 'sports related trauma' showed the highest OR of 4.6 (95% CI = 2.2 to 9.3) for a positive MRI finding. Clinical scores were statistically, significantly worse in patients with positive MRI findings, with mean differences ranging from 10 to 20%. Furthermore, increasing duration of complaints was correlated with decreasing prevalence rates of positive MRI findings. Overall, a popping sound and direct swelling showed the highest positive predictive value of 65% for the presence of positive MRI findings.

CONCLUSION

The results from this study enable a preselection of patients to increase the diagnostic yield of MRI in primary care.

Clinical diagnostic accuracy and magnetic resonance imaging of patients referred by physical therapists, orthopaedic surgeons, and nonorthopaedic providers

STUDY DESIGN

Nonexperimental, retrospective design.

OBJECTIVES

This study was designed to compare clinical diagnostic accuracy (CDA) between physical therapists (PTs), orthopaedic surgeons (OSs), and nonorthopaedic providers (NOPs) at Keller Army Community Hospital on patients with musculoskeletal injuries (MSI) referred for magnetic resonance imaging (MRI).

BACKGROUND

US Army PTs are frequently the first credentialed providers privileged to examine and diagnose patients with musculoskeletal injuries. Physical therapists assigned at Keller Army Community Hospital have also been credentialed with privileges to order MRI studies for several years.

METHODS AND MEASURES

To reduce provider bias, a retrospective analysis was performed on 560 patients referred for MRI over an 18-month period. An electronic review of each patient's radiological profile was performed to assess agreement between clinical diagnosis and MRI findings. Data analyses were performed through descriptive statistics and contingency tables.

RESULTS

Analysis on agreement between clinical diagnosis and MRI findings produced a CDA of 74.5% (108/145) for PTs, 80.8% (139/172) for OSs, and 35.4% (86/243) for NOPs. There was a significant difference in CDA between PTs and NOPs (P<.001), and between OSs and NOPs (P<.001). There was no difference in CDA between PTs and OSs (P>.05).

CONCLUSIONS

Clinical diagnostic accuracy by PTs and OSs on patients with musculoskeletal injuries was significantly greater than for NOPs, with no difference noted between PTs and OSs.

Bone injury associated with anterior cruciate ligament and meniscal tears: assessment with bone single photon emission computed tomography

RATIONALE AND OBJECTIVES

Acute injury of the menisci and ligaments about the knee joint is often associated with accompanying bone injury. The role of bone single photon emission computed tomography (SPECT) was assessed in this clinical setting.

MATERIALS AND METHODS

Knee SPECT was performed in 94 patients with suspected ACL, meniscal tear, or both and was correlated with arthroscopy (n = 74), magnetic resonance imaging (MRI) (n = 37), or both. Scintigraphic findings were categorized based on their anatomic location and on uptake intensity (0-3 grade scale).

RESULTS

Correlation with arthroscopy: Eleven patients had a normal arthroscopy of which in 10, SPECT images detected no abnormality. Sixty-three patients had abnormal arthroscopic findings, whereas all had abnormal SPECT studies. Thirty-eight patients had an anterior cruciate ligament (ACL) tear on arthroscopy. In this type of injury SPECT images detected increased uptake in the posterior aspect of the lateral tibial plateau (LTPp) with a positive predictive value (PPV) of 93% and a negative predictive value (NPV) of 97%. In 55% of the patients, increased uptake was also detected in the region of the middle sulcus of the lateral femoral condyle (LFCm): a "kissing" pattern. Tear of the medial meniscus was diagnosed by arthroscopy in 43 patients. SPECT images detected increased uptake in the medial tibial plateau (MTP) with a PPV of 78% and a NPV of 83%. Correlation with MRI: all seven cortical fractures seen on MRI were detected on SPECT. Twenty-eight patients had MRI findings suggestive of an ACL injury. Accompanying bone bruises were seen in 18 of them (64%). On SPECT images, all 28 patients with an ACL tear had increased uptake in the LTPp. Intensity of uptake in patients with associated bone bruise, however, was significantly higher; mean intensity grade 2.4 +/- 0.7 in case of accompanying bone bruise compared with 1.4 +/- 0.8 in case of an ACL tear without associated bone injury, P< 0.01.

CONCLUSION

Results of the study suggest that bone SPECT is valuable in acute knee trauma for assessment of ACL, meniscal tears, or both and for detection of associated bone injury.