Repeat Imaging Changes Diagnosis?

How often are X-rays repeated when patients appear for an initial orthopedic appointment? And when they are, how often does this change the diagnosis and/or management of the case?

These questions were posed by a team from Rothman Orthopaedic Institute in Philadelphia, Pennsylvania. Their research, “The Frequency, Reasoning, and Impact of Repeated Radiographs at the Initial Orthopedic Arthroplasty Visit,” appears in the July 17, 2021, edition of The Journal of Arthroplasty.

Co-author Arjun Saxena, M.D., M.B.A., a Rothman adult hip and knee reconstruction surgeon, explained to OTW the issue of shifting diagnosis based on repeated images, “This research stemmed from our observations in the orthopaedic clinic. Too often, especially for joint replacement surgeons, we see patients who present with inadequate X-rays for evaluation. Appropriate X-rays—whether it be the appropriate views, quality, or standing versus sitting—are very important to determine an accurate diagnosis. We decided to attempt to quantify a number of parameters with regards to patients who present with outside imaging.”

The researchers prospectively enrolled patients (18 years or older) with hip and/or knee pain at five arthroplasty clinics from January 2019 until June 2020. Patients completed pre-visit surveys about the reason for their visit, prior care, and prior diagnostic imaging. Following the initial visit, surgeons collected data on the number of new radiographs obtained, the reasoning behind the decision to acquire new films, and if the diagnosis or management changed as a result.

Of 292 patients:

• 256 (88%) had X-rays prior to their office visit
• 167 (65%) were sent for repeat radiographs.
• And the reasons for repeat X-rays?
• 47% of the time, the prior X-ray wasn’t available
• 40% of the time, the prior X-ray was non-weight-bearing
• Altered diagnosis, altered management

“We observed a change in diagnosis 40% of the time and a change in management 22% of the time,” Dr. Saxena explained to OTW. “This was not really a surprise as we have seen so many patients present with limited X-rays or non-weightbearing X-rays.”

“We found that 88% of patients in this cohort presented with imaging prior to the visit and 65% of the patients underwent repeat imaging. This has significant implications as the X-rays taken prior to the visit are essentially unnecessary and represent wasted healthcare dollars.”

“Equally or even more importantly, these unused studies represent a loss of time (possibly from work) for the patients who take time to have X-rays performed and then end up having the studies repeated anyway. It is important to educate x-ray technicians and clinical providers on the appropriate films required for initial evaluation. Additionally, orthopaedic providers should inform referring practices about their imaging capabilities as obtaining images at the visit may streamline the process for patients.”