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Evidence review for additional benefit of imaging in the diagnosis of osteoarthritis

Osteoarthritis in over 16s: diagnosis and management

Evidence review A

NICE Guideline, No. 226

London: National Institute for Health and Care Excellence (NICE); .
ISBN-13: 978-1-4731-4740-9

1. Additional benefit of imaging in the diagnosis of osteoarthritis

1.1. Review question

What is the clinical and cost-effectiveness of using imaging in the diagnosis of osteoarthritis in people with suspected osteoarthritis?

1.1.1. Introduction

In the absence of red flag signs or symptoms, the diagnosis of osteoarthritis can be achieved through clinical assessment (history taking and examination). Imaging findings do not always correlate well with the patient’s symptoms, particularly in the early stages of osteoarthritis, and management is not dictated by imaging results alone. There is no gold standard for the clinical diagnosis of osteoarthritis and multiple clinical and research focussed definitions of the condition have been developed and some patients expect imaging to confirm a diagnosis. Imaging continues to be frequently used despite uncertainties about the benefit this adds to the diagnosis, the resource implications and potential for delays in commencing management. X-ray is the most common imaging used for knee osteoarthritis, however magnetic resonance imaging (MRI) is now being used more commonly to examining soft tissues and to pick up more subtle bony changes. Some healthcare professionals may use ultrasound for more superficial joints (for example: finger, toe). In some parts of the country, primary care has direct access to MRI and ultrasound scans. The aim of this review is to establish if there is additional benefit in using any imaging as an adjunct to clinical examination to diagnose osteoarthritis. This review does not seek to define when imaging is indicated in the natural history of osteoarthritis.

1.1.2. Summary of the protocol

For full details see the review protocol in Appendix A.

Table 1. PICO characteristics of review question.

Table 1

PICO characteristics of review question.

1.1.3. Methods and process

This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual. Methods specific to this review question are described in the review protocol in appendix A and the methods document.

Declarations of interest were recorded according to NICE’s conflicts of interest policy.

1.1.4. Effectiveness evidence

1.1.4.1. Included studies

No relevant clinical studies comparing diagnosis based on different imaging techniques to each other were identified.

This review aimed to investigate the diagnostic effectiveness rather than the diagnostic accuracy of techniques. This was as the committee agreed that there was no gold standard test that would be used to diagnose osteoarthritis, as osteoarthritis is a clinical syndrome and may or may not have imaging features associated with it. Given this, the committee decided to investigate if there was additional benefit to using imaging on long-term outcomes for people with osteoarthritis. No studies fulfilled this criterion while reporting outcomes included in the protocol.

See also the study selection flow chart in Appendix C.

1.1.4.2. Excluded studies

See the excluded studies list in Appendix J.

1.1.5. Summary of studies included in the effectiveness evidence

No evidence was identified for this review.

1.1.6. Summary of the effectiveness evidence

No evidence was identified for this review.

1.1.7. Economic evidence

1.1.7.1. Included studies

No health economic studies were included.

1.1.7.2. Excluded studies

No relevant health economic studies were excluded due to limited applicability or methodological limitations.

See also the health economic study selection flow chart in Appendix G.

1.1.8. Summary of included economic evidence

There was no economic evidence found.

1.1.9. Economic model

This area was not prioritised for new cost-effectiveness analysis

1.1.10. Unit costs

Relevant unit costs are provided below to aid consideration of cost effectiveness.

1.1.11. Economic evidence statements

  • No relevant economic evaluations were identified.

1.1.12. The committee’s discussion and interpretation of the evidence

1.1.12.1. The outcomes that matter most

The critical outcomes were quality of life, pain and physical function. These were considered critical due to their relevance importance to people with osteoarthritis. The Osteoarthritis Research Society International (OARSI) consider that pain and physical function were the most important outcomes for evaluating interventions. Quality of life gives a broader perspective on the person’s wellbeing, allowing for examination of the biopsychosocial impact of interventions. Psychological distress, healthcare utilisation and any alternative diagnosis were included as important outcomes.

Mortality was not considered in this review. Osteoarthritis as a disease process is not considered to cause mortality by itself and mortality is an uncommon outcome from osteoarthritis interventions. The committee agreed that the intervention from this review were unlikely to cause mortality rates to change. Given this, the committee did not feel that mortality required a specific outcome.

The committee considered if a diagnostic accuracy review was appropriate. During discussion of the protocol, it was agreed that there was no consistent gold standard test that could be used for a diagnostic accuracy review (as people may have findings consistent with osteoarthritis on imaging but not have clinical symptoms of osteoarthritis, and people may have no findings on imaging yet have clinical symptoms of osteoarthritis). Therefore, a test-and-treat review was conducted. However, no outcome data was available for this review.

1.1.12.2. The quality of the evidence

No evidence was identified for this review.

1.1.12.3. Benefits and harms

No evidence was identified for this review. Therefore, the committee discussion was based on expert opinion.

The committee considered the potential benefits and harms of imaging. The committee considered that imaging findings consistent with osteoarthritis may not indicate that someone’s clinical symptoms are due to osteoarthritis. Current practice in the United Kingdom considers osteoarthritis as a clinical syndrome consisting of activity-related joint pain with morning stiffness that lasts no longer than 30 minutes (or no morning joint-related stiffness) that generally occurs in people 45 years or over.

Based on the absence of evidence, the committee agreed that imaging is unlikely to provide benefit for diagnosing osteoarthritis. Based on these factors the committee agreed recommending that there is no evidence to support the use of imaging in addition to clinical assessment for people with osteoarthritis unless there are atypical features or features that suggest an alternative or additional diagnosis such as other inflammatory arthritis (for example, rheumatoid arthritis) and malignancy. These conditions are less common than osteoarthritis but can have significant consequences if they are not identified. Atypical features could include: a history of recent trauma, prolonged morning joint-related stiffness, rapid worsening of symptoms or deformity, the presence of a hot swollen joint, or concerns that may suggest infection or malignancy. While the committee agreed these features could prompt further investigation (including imaging) they also noted that imaging may not always be the optimal investigation in these cases.

Overall, the committee agreed that it is widely accepted that diagnosis is achieved through clinical assessment, that imaging proffers no benefit and that there was no evidence to change current practice. They also agreed that further research is not warranted, and no research recommendation has been made.

1.1.12.4. Cost effectiveness and resource use

No economic evaluations were identified for inclusion in this review

NHS reference costs data suggested that the cost of imaging ranges between £56 and £173, with the cheapest option being x-ray imaging and the most expensive being an MRI scan. Imaging is currently used routinely in the diagnosis of osteoarthritis. Given the incidence of osteoarthritis, a change in practice would potentially cause a substantial cost impact in either direction.

In the absence of evidence of clinical effectiveness or cost effectiveness the committee did not recommend imaging for the diagnosis of osteoarthritis. The committee’s recommendation should result in a reduction in NHS resource use and ultimately be a cost saving measure.

1.1.12.5. Other factors the committee took into account

The committee noted that there is NICE guidance relating to some of the differential diagnoses that may be relevant when assessing people with osteoarthritis. These may contain recommendations for imaging and other investigations (including blood tests) that could be used. These include:

The committee agreed that a research recommendation was not required in this area. While studies were not identified in the review, the committee agreed through consensus that there was limited value to be gained from the use of imaging in the diagnosis of osteoarthritis, as osteoarthritis is defined as a clinical syndrome of joint pain accompanied by varying degrees of functional limitation and reduced quality of life. The committee noted that observational evidence indicated that people with imaging features related to osteoarthritis may be symptomatic and may not develop symptoms. Given this, further research is unlikely to change understanding in this area.

The committee noted that the osteoarthritis research in general did not appear to represent the diverse community of people who can have osteoarthritis. While future research is not recommended in this area, they agreed that any future research should be representative of the population, including people from different family backgrounds, and socioeconomic backgrounds, disabled people, and people of different ages and genders. This should be done to consider the different experiences of people from diverse communities to ensure that the approach taken can be made equitable for everyone.

1.1.13. Recommendations supported by this evidence review

This evidence review supports recommendations 1.1.1 to 1.1.2. Other evidence supporting these recommendations can be found in Evidence Review A.

1.1.14. References

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Appendices

Appendix B. Literature search strategies

  • What is clinical and cost-effectiveness of using imaging in the diagnosis of osteoarthritis in people with suspected osteoarthritis?

The literature searches for this review are detailed below and complied with the methodology outlined in Developing NICE guidelines: the manual.34

For more information, please see the Methodology review published as part of the accompanying documents for this guideline.

B.1. Clinical search literature search strategy (PDF, 204K)

B.2. Health Economics literature search strategy (PDF, 161K)

Appendix D. Effectiveness evidence

No studies were included.

Appendix E. Forest plots

No studies were included.

Appendix F. GRADE tables

No studies were included.

Appendix G. Economic evidence study selection

Download PDF (164K)

Appendix H. Economic evidence tables

There were no health economic studies found in the review

Appendix I. Health economic model

No original economic modelling was undertaken.

Appendix J. Excluded studies

Clinical studies

Table 5Studies excluded from the clinical review

ReferenceReason for exclusion
Abedin 20191Incorrect comparison (comparing different models of diagnosis using the same imaging modality)
Agoda-Koussema 20122Not in English.
Alvarez 20053Non-comparative study.
Amitai 20154Included people with rheumatoid arthritis. Diagnostic accuracy study.
Atar 20195Incorrect comparison (comparing serum endothelin levels with clinical/sonographic measurements)
Badel 20126Incorrect comparison. Diagnostic accuracy study.
Baker 20207Incorrect comparison (comparing bone scan to magnetic resonance imaging). No usable outcomes.
Boegard 20038Incorrect comparison. Cross-sectional study comparing people with and without radiographic evidence of osteoarthritis.
Brandt 20009Incorrect comparison (comparing people with radiographic knee osteoarthritis to people without radiographic knee osteoarthritis).
Breasley 200710Excludes people with osteoarthritis.
Cai 202011Incorrect comparison (comparing people with osteoarthritis on knee radiograph, osteoarthritis on magnetic resonance imaging, both and neither to each other)
Chen 201513Incorrect comparison (compares people with ultrasound grades of osteoarthritis)
Chen 202012Incorrect population (including people with knee osteoarthritis confirmed by arthroscopy and healthy participants)
Chiba 201614Incorrect comparison (compared people with different grades of radiographic knee osteoarthritis with the presence of effusion on ultrasound)
Emshoff 200115Diagnostic accuracy study. No usable outcomes.
Ezzat 201316Incorrect comparison (compared people with and without radiographic, symptomatic and magnetic resonance imaging evidence of osteoarthritis when all participants had all of the types of imaging)
Gluckert 199017Not in English
Haghighi 201718Incorrect comparison (investigated a correlation between ultrasound, radiographic and symptomatic osteoarthritis using the same imaging on all participants)
Hirsch 201719Incorrect comparison (investigates the use of imaging guidance for intra-articular injections)
Ip 201120Incorrect comparison (compares people with different severities of radiographic osteoarthritis to magnetic resonance imaging findings where all people had both imaging techniques performed).
Javaid 201221Incorrect comparison (compares people with radiographic osteoarthritis to magnetic resonance imaging findings where all people had both imaging techniques performed).
Keen 200922Systematic review with a different PICO to that in the protocol (investigating ultrasound scoring systems).
Kim 200823Incorrect intervention (bone scan).
Kim 201724Incorrect comparison (investigates findings on SPECT/CT).
Kinds 201125Systematic review with a different PICO to that in the protocol (investigating radiographic severity in people with symptomatic osteoarthritis)
Kroon 201826Wrong study type (cross-sectional study)
Laursen 201627Incorrect comparison (imaging post-surgical prosthesis insertion)
Macri 202128Wrong study type (cross-sectional study)
Magnusson 201829Incorrect comparison (all participants had imaging at the start of the study)
Matsos 200930Incorrect comparison (includes people without osteoarthritis)
Menz 202131Wrong study type (cross-sectional study)
Mortada 201632Incorrect comparison (investigating diagnostic accuracy in people who had all had ultrasound scans)
Nalamachu 202033Wrong study type (cross-sectional study)
Neiman 201635Incorrect intervention (magnetic resonance arthrography obtained with all participants including people without osteoarthritis)
Pan 201937Incorrect comparison (investigating different phenotypes of knee pain. All people had imaging).
Park 201238Wrong population (includes people with temporomandibular joint disorders, not just osteoarthritis)
Roberts 201539Incorrect comparison (compares people evaluated by primary care physicians and people evaluated by staff orthopaedic surgeons).
Roux 201640Incorrect comparison (compares semi-flexed x-ray to anteroposterior extended and semi-flexed x-ray).
Sheridan 202141Incorrect population (including people with meniscal tears as well as people with knee osteoarthritis)
Smink 201442Incorrect comparison (investigating the implementation of a stepped care sequence).
Thomas 200843No relevant outcomes (reports dichotomous outcomes for values that the protocol specifies should be reported as continuous outcomes).
Wang 201845Incorrect comparison (compares people with and without radiographic knee osteoarthritis).
Wang 202144Incorrect intervention (predictors for early stage arthritis- all people had imaging)
Whittaker 201846Incorrect comparison (compares people with and without magnetic resonance imaging osteoarthritis).
Yoong 201247Incorrect comparison (investigating image guided intra-articular injections).
Zhu 201748Incorrect comparison (compares people with different severities of imaging, all people had magnetic resonance imaging).

Health Economic studies

Published health economic studies that met the inclusion criteria (relevant population, comparators, economic study design, published 2005 or later and not from non-OECD country or USA) but that were excluded following appraisal of applicability and methodological quality are listed below. See the health economic protocol for more details.

None.

Final

Evidence reviews underpinning recommendations 1.1.1 to 1.1.2 in the NICE guideline

Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.

Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.

Copyright © NICE 2022.
Bookshelf ID: NBK589217PMID: 36791239

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