Australian Rheumatology Association: tests, treatments and procedures clinicians and consumers should question

There is consistent evidence to indicate that arthroscopic lavage and/or debridement to treat people for symptomatic knee osteoarthritis, and/or partial meniscectomy for patients with a degenerate meniscal tear (with or without underlying osteoarthritis), is no more effective than placebo surgery or non-operative alternatives.

There appears to be a high rate of conversion from knee arthroscopy to total knee arthroplasty, which rises with increased age, further suggesting arthroscopic surgery should be avoided in people over the age of 50 years. Additionally, arthroscopy is associated with peri- and post-operative risks and considerable cost.

Supporting evidence

  • Buchbinder R, Richards B, Harris I. Knee osteoarthritis and role for surgical intervention: lessons learned from randomized clinical trials and population-based cohorts. Curr Opin Rheumatol 2014; 26:138-44.
  • Fedorka CJ, Cerynik DL, Tauberg B, et al. The relationship between knee arthroscopy and arthroplasty in patients under 65 years of age. J Arthroplasty 2014; 29:335-38.
  • Khan M, Evaniew N, Bedi A, et al. Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis. CMAJ 2014; 186:1057-64.
  • Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med 2013; 368:1675-84.
  • Sihvonen R, Paavola M, Malmivaara A, et al. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med 2013; 369:2515-24.
  • Thorlund JB, Juhl CB, Roos EM, et al. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ 2015; 350:h2747.
  • Wai EK, Kreder HJ, Williams JI. Arthroscopic débridement of the knee for osteoarthritis in patients fifty years of age or older: utilization and outcomes in the Province of Ontario. J Bone Joint Surg Am 2002; 84-A:17-22.

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Antinuclear antibodies (ANAs) are present in healthy individuals and ANA testing is only useful in patients with symptoms and/or signs of a rheumatic disease where it can aid in the confirmation or exclusion of systemic connective tissues diseases. ANA testing has a very high negative predictive value for excluding connective tissue diseases as a cause for patients’ symptoms. However, a positive ANA result does not have a high positive predictive value for diagnosing these conditions in isolation, and further sub-serology testing is needed to accurately diagnose and classify these conditions.

Supporting evidence

  • Agmon-Levin N, Damoiseaux J, Kallenberg C, et al. International recommendations for the assessment of autoantibodies to cellular antigens referred to as anti-nuclear antibodies. Ann Rheum Dis 2014; 73:17-23.
  • British Columbia Guidelines: Antinuclear Antibody (ANA) Testing for Connective Tissue Disease [homepage on the Internet] British Columbia: Ministry of Health [updated 1 June 2013; cited 18 Sept 2017]. Available at: http://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bcguidelines/ana-testing.
  • Solomon DH, Kavanaugh AJ, Schur PH. Evidence-based guidelines for the use of immunologic tests: antinuclear antibody testing. Arthritis Rheum 2002; 47:434-44.

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Most episodes of low back pain (~90%) do not require imaging. Imaging may identify irrelevant incidental findings and increase the risk of exposure to unnecessary, and sometimes invasive treatment, in addition to increasing costs. For patients with low back pain and no suggestion of serious underlying conditions there are no significant differences in pain or disability outcomes between immediate imaging as compared with usual care without imaging.

Supporting evidence

  • Graves JM, Fulton-Kehoe D, Martin DP, et al. Factors associated with early magnetic resonance imaging utilization for acute occupational low back pain: a population-based study from Washington State workers' compensation. Spine 2012; 37:1708-18.
  • Jarvik JG, Gold LS, Comstock BA, et al. Association of early imaging for back pain with clinical outcomes in older adults. JAMA 2015; 313:1143-53.
  • Suri P, Boyko EJ, Goldberg J, et al. Longitudinal associations between incident lumbar spine MRI findings and chronic low back pain or radicular symptoms: retrospective analysis of data from the longitudinal assessment of imaging and disability of the back (LAIDBACK). BMC Musculoskel Dis 2014, 15:152.
  • Webster BS, Bauer AZ, Choi Y, et al. Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling low back pain. Spine 2013; 38:1939-46.

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Currently there is no high-quality evidence to support the superiority of ultrasound-guided subacromial injections compared with injections guided by landmarks alone. Based upon moderate quality evidence from five trials, a Cochrane review was unable to find any advantage (in terms of pain, function, range of motion or adverse events) of ultrasound-guided injection over either landmark-guided or intramuscular injection. These results are consistent with a more recent trial. In view of the currently available data and the significant added cost, there is little clinical justification in using ultrasound to guide injections for shoulder pain.

Supporting evidence

  • Bloom JE, Rischin A, Johnston RV, et al. Image-guided versus blind glucocorticoid injection for shoulder pain. Cochrane Database System Rev 2012; 8:CD009147.
  • Dogu B, Yucel SD, Sag SY, et al. Blind or ultrasound-guided corticosteroid injections and short-term response in subacromial impingement syndrome: a randomized, double-blind, prospective study. Am J Phys Med Rehabil 2012; 91:658-65.

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International recommendations advise testing for anti-dsDNA antibodies only after detecting a positive ANA in patients with symptoms consistent with systemic lupus erythematosus. In patients who are ANA negative, anti-dsDNA should only be ordered in clinical situations where the pre-test probability of SLE is very high. Where positive, repeating anti-dsDNA antibodies titres is a useful test for monitoring disease activity, especially in lupus nephritis.

Supporting evidence

  • Agmon-Levin N, Damoiseaux J, Kallenberg C, et al. International recommendations for the assessment of autoantibodies to cellular antigens referred to as anti-nuclear antibodies. Ann Rheum Dis 2014; 73:17-23.
  • Kavanaugh AF, Solomon DH. Guidelines for immunologic laboratory testing in the rheumatic diseases: anti-DNA antibody tests. Arthritis Rheum 2002; 47:546-55.
  • Linnik MD, Hu JZ, Heilbrunn KR, et al. Relationship between anti-double-stranded DNA antibodies and exacerbation of renal disease in patients with systemic lupus erythematosus. Arthritis Rheum 2005; 52:1129-37.

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Last reviewed 06 February 2018