Abstract
Objective
Radiographic osteoarthritis of the acromioclavicular joint (ACJ OA) is a common incidental finding and an uncommon reason for people to seek care for shoulder symptoms. We reviewed the published evidence regarding the age-specific prevalence of ACJ OA to establish the base rate of pathophysiology.
Methods
A total of 10 studies including 1831 shoulders met our criteria. A pooled analysis was done to obtain a proportion of subjects with ACJ OA across age categories.
Results
Forty-eight percent of 953 cadaver and skeletal specimens and 70% of 210 MRI images of asymptomatic shoulders were found to have changes consistent with ACJ OA. Four studies reporting age as a continuous variable found a statistically significant association between older age and prevalence of ACJ OA.
Conclusions
The observation that ACJ OA is highly prevalent as humans age establishes a very high base rate of what one can infer is well-accommodated disease. Given that a high base rate of incidental disease creates a low pre-test odds that radiological findings of disease correspond with symptoms, diagnosis of symptomatic ACJ OA is subject to substantial inaccuracy and should be made sparingly, mindful of the potential harms of a diagnosis that can lead to an ablative surgery.
Keywords: Acromioclavicular joint, Osteoarthritis, Prevalence, Age
1. Introduction
Acromioclavicular joint osteoarthritis (ACJ OA) is a relatively uncommon reason for people to seek care for shoulder pain. The ACJ is relatively immobile having 4.3° of internal rotation, 14.6° of upward rotation, and 6.7° of posterior tilting during scapular plane abduction from rest to 90°.1 Radiological signs of ACJ OA are highly prevalent and may be incidental to common causes of shoulder pain such as rotator cuff tendinopathy, which is by far the number one cause for a person to seek care for atraumatic pain in the arm. In a study of arthroscopic surgical findings of 218 shoulders of individuals diagnosed with symptoms from ACJ OA, all but 5 had findings of coexisting pathology including rotator cuff tendinopathy (including long head of biceps tendinopathy) in 81% and labral changes (likely degenerative) in 33%.2 An understanding of the base rate of radiological signs of ACJ OA in the general population is important to making an accurate diagnosis of symptomatic ACJ OA.
Medical diagnosis is based on clinician interpretation of symptoms and signs confirmed by selective diagnostic tests. The goal is to identify a pathophysiology (disease) that is associated with the illness (symptoms and activity intolerance). In estimating the probability that an illness is due to a specific measurable disease, it is important to understand the base rate of well-accommodated disease within the population that the individual patient represents. Even a highly sensitive and specific test can be misleading when the base rate of pathology is very high or very low.3 If radiographic ACJ OA is a common incidental finding, and given that symptomatic ACJ OA is an uncommon diagnosis among people seeking care for shoulder pain, then the pre-test probability that radiological findings account for shoulder symptoms is low, which will lower the diagnostic performance (positive predictive value) of even the most accurate and reliable test. And even an accurate and reliable test should improve health, and that is not established for diagnosis of symptomatic ACJ OA.4
There is a substantial risk that symptoms from common sources of shoulder pain such as rotator cuff tendinopathy will be falsely ascribed to incidental ACJ OA.5 This is a type of base rate fallacy. Such cognitive biases are an important source of potential error in musculoskeletal medicine. A study presenting hypothetical vignettes to 196 orthopedic surgeons found that surgeons are susceptible to cognitive biases including base rate neglect, confirmation bias, anchoring, and framing effect.6 Misdiagnosis due to base rate neglect can lead to tests and treatments with potential for harm and no potential for benefit beyond non-specific effects such as the placebo and nocebo effects.
Many clinicians are aware of the high base rate of incidental ACJ OA, but others are not. And we found it was surprisingly poorly documented. This systematic review addressed the published evidence on the age-associated prevalence of ACJ OA.
2. Methods
2.1. Protocol and registration
This systematic review was done following guidelines from the Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement.7 It has been registered with PROSPERO, registration number CRD42020201737 (Appendix B).
2.2. Selection criteria
All studies addressing the prevalence of ACJ OA in people not presenting for care of shoulder pain were considered for this systematic review. The human populations studied included cadavers, skeletons, and living individuals. There were no exclusions for comorbidities, illnesses, race, ethnicity, or gender. The exposure variable was age as a continuous or categorical variable. The outcome of interest was presence of ACJ OA defined by narrowing of the AC joint and osteophyte formation visible on radiographs or on direct inspection of skeletons.
2.3. Search strategy
We searched PubMed and SCOPUS for articles up to June 22, 2020. Search terms included “acromioclavicular joint” (or “acromioclavicular joint,” “ACJ,” “acromioclavicular arthritis”), “osteoarthritis” (or “OA,” “degenerative joint disease”) and “radiography” (or “X-ray”) (Appendix B). The search yielded a total of 268 studies: 100 studies from PubMed and 158 studies from SCOPUS. Non-English studies, case reports, abstracts, and reviews were excluded. A full text review was done of references in included studies to screen for other articles meeting inclusion criteria (Fig. 1). While doing so, a low overall number of studies were obtained and a few MRI studies were identified that were not included in the results of the search using radiographs. The decision was made to expand the PubMed search with new terminology (“diagnostic imaging” instead of “radiography”) that would not only find studies evaluating radiography but also studies evaluating magnetic resonance imaging, computed tomography, and ultrasound findings (Appendix B). No new studies were found that met the inclusion criteria.
Fig. 1.
Flow diagram of study selection.
2.4. Data extraction
Records were screened using Rayyan QCRI (Qatar Computing Research Institute, Doha, Qatar),8 a web application for collaboratively filtering studies, by one reviewer and checked by another reviewer. Disagreements were resolved by the senior author.
Data extracted from screened articles include study design, imaging type, subject demographics, number of subjects with ACJ OA by age group and/or measures of effect including odds ratios, correlation, and Cohen's d. Data was extracted by one reviewer and checked by another reviewer, with disagreements resolved by the senior author. Data was collected and managed using an excel spreadsheet and word document.
2.5. Risk of bias assessment
Two reviewers performed the quality assessment of the studies with disagreements addressed by a third reviewer. Assessment of the quality of the included studies was at the study level. We adapted content from the Quality Assessment Checklist for Prevalence Studies by Hoy et al.9 and the structure of the Newcastle-Ottawa Quality Assessment Scale for Case Control Studies,10 to assess the quality of the included studies. Study characteristics assessed include representativeness of the population compared to the target population, method of age determination, and assessment and classification of ACJ OA. The adapted scale provides a maximum of 4 stars for each of these factors.
A pooled analysis was done by combining the number of subjects with and without ACJ OA from each study to obtain a proportion of subjects with ACJ OA across age categories. The following data were extracted: sample size, specimen, identification method (i.e. direct inspection, radiograph, CT, MRI) and prevalence by age. For studies reporting age associations with ACJ OA, p-values and additional statistical analyses were extracted.
3. Results
3.1. Study characteristics
A total of 1831 shoulders across 10 studies were included in this review (Table 1). One study used direct inspection of skeletons,11 1 study used imaging of Egyptian mummies,12 2 studies used radiographs of skeletons,13, 14 2 studies used radiographs of living individuals,15,16 and 4 studies used MRI of living individuals.17, 18, 19, 20 Six of these studies evaluated age categorically and 4 continuously.
Table 1.
Study baseline characteristics.
| Study | Design | ROB | Specimen | Identification Method | Age | N | ACJ OA | Prev (%) |
|---|---|---|---|---|---|---|---|---|
| Fritsch et al. | Retrospective | 2 | Ancient Egyptian mummies | CT | Categorical | 52 | 13 | 25 |
| Gumina et al. | Retrospective | 2 | Clavicles of skeletons | X-ray | Categorical | 509 | 316 | 62 |
| Nicholson et al. | Retrospective | 2 | Scapulas of skeletons | Direct inspection | Categorical | 395 | 128 | 32 |
| Petersson et al. | Cross-sectional | 2 | Cadaver shoulders | Direct inspection | Continuous | 168 | 149 | 89 |
| Needell et al. | Cross-sectional | 3 | Asymptomatic shoulders | MRI | Categorical | 100 | 76 | 76 |
| Liou et al. | Cross-sectional | 2 | Asymptomatic shoulders | MRI | Categorical | 60 | 29 | 48 |
| Stein et al. | Cross-sectional | 3 | Asymptomatic shoulders | MRI | Categorical | 50 | 40 or 41* | 80–82 |
| Bonsell et al. | Cross-sectional | 3 | Asymptomatic shoulder | X-ray | Continuous | 84 | 38 | 45 |
| Pennington et al. | Cross-sectional | 4 | Random shoulders | X-ray | Continuous | 240 | X | X |
| Eriks-Hoogland et al. | Cross-sectional | 4 | 68 spinal cord injury and 105 able-bodied persons | MRI | Continuous | 173 | 163 | 94 |
| Total | 1831 | 912 | 50 | |||||
X = Not provided; ROB = Risk of bias scale; N = total sample; ACJ OA = sample with osteoarthritis; Prev = prevalence; *inconsistency in article.
3.2. Risk of bias within studies
Five out of 10 studies earned a score of 3 or 4 and the remaining five earned 2 out of 4 (Appendix C). Three studies in the latter group utilized cadavers as their outcome identification method, a potential source of bias as it is difficult to optimize representativeness of the sample and accurately determine age in this population.
3.3. Results of individual studies
Out of 953 pooled mummy and skeletal specimens, 457 (48%) had identifiable ACJ OA. 66% of cadaver ACJs were found to have osteoarthritis over the age of 61, compared to 53% in the 41–60 age group and 25% in ages 21–40 (Fig. 2).12, 13, 14
Fig. 2.
Prevalence of ACJ OA by age group across Fritch et al., Gumina et al., and Nicholson et al. studies.
In a study examining 100 asymptomatic shoulders, 90% of individuals aged 61–88 had MRI findings of ACJ OA compared to 89% in the 40–60 age group and 39% in the 19–39 age group.19 In a study with 60 asymptomatic shoulders, 80% of individuals greater than 40 years of age showed MRI evidence of ACJ OA compared to 47% in ages 31–40 and 19% in ages 21–30.18 A study with 50 asymptomatic shoulders described that 27 or 28 (90–93%; conflicting numbers in the paper) of individuals over 30 years of age had arthritic changes on MRI, compared to 68% in the under 30 age group (Table 2).20
Table 2.
Prevalence of ACJ osteoarthritis by age category.
| Study | N | ACJ OA | Prev (%) | =<20 | 21–30 | 31–40 | 41–50 | 51–60 | 61–70 | 71–80 | >80 |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Fritsch et al. | 52 | 13 | 25 | 0/3 (0%) | 3/14 (21%) | 3/9 (33%) | 4/18 (22%) | 2/7 (29%) | 1/1 (100%) | ||
| Gumina et al. | 509 | 316 | 62 | X | 64/113 (57%) | 111/171 (65%) | 141/226 (62%) | ||||
| Nicholson et al. | 395 | 128 | 32 | X | 0/102 (0%) | 7/71 (10%) | 16/73 (22%) | 51/77 (66%) | 54/72 (75%) | X | |
| Needell et al. | 100 | 76 | 76 | X | 10/26 (39%) | 23/26 (89%) | 43/48 (90%) | ||||
| Liou et al. | 60 | 29 | 48 | X | 4/21 (19%) | 9/19 (47%) | 16/20 (80%) | ||||
| Stein et al. | 50 | 41 | 82 | 13/19 (68%) | 27 or 28*/30 (90–93%) | ||||||
| Total | 1166 | 603 | 52 | ||||||||
X: Not provided; N = total sample; ACJ OA = sample with osteoarthritis; Prev = prevalence; *inconsistency in article.
All four studies using age as a continuous variable found a statistically significant (p < 0.01) association between increasing age and ACJ OA using radiographs, MRI, and direct inspection of cadaver dissections (Table 3).11,15, 16, 17 One study found that increasing age was significantly associated with narrowing (OR = 1.067, p = 0.001) and degeneration (OR = 1.080, p < 0.001) of the AC joint on radiographs.15 In another study, the stigmata of ACJ OA on radiographs including sclerosis and osteophytes increased significantly with advancing age (Spearman's rank = 0.65, p < 0.01) and the width of the AC joint space decreased significantly with advancing age (Spearman's rank = −0.40, p < 0.01).16 Another study found that the odds of having increasingly severe ACJ OA evaluated by MRI was 10% higher per additional year of age (Adj OR = 1.10, p < 0.0001).17
Table 3.
Age association with ACJ OA.
| Study | N | P value | Statistical Analyses |
|---|---|---|---|
| Bonsell et al. | 84 | p < 0.001 | OR = 1.080 |
| Pennington et al. | 340 | p < 0.01 | Spearman's rank = 0.65 |
| Petersson et al. | 168 | p < 0.001 | t-test |
| Eriks-Hoogland et al. | 173 | p < 0.0001 | Adjusted OR = 1.10 |
| Total | 765 | p < 0.01 |
X: Not provided; N = total sample; OR = odds ratio.
3.4. Synthesis of results
ACJ OA is a prevalent finding in cadavers and asymptomatic shoulders. 48% of 953 cadavers and 70% of 210 asymptomatic shoulders were found to have ACJ OA. The prevalence of ACJ OA in cadavers and in asymptomatic shoulders increases with advancing age. Furthermore, four studies with varying identification methods reporting age as a continuous variable showed a statistically significant (p < 0.01) association between age and ACJ OA.
4. Discussion
High quality evidence that interventions for ACJ OA improve symptoms and capability better than simulated interventions is lacking. Add to that the potential that a base rate fallacy may result in symptoms being falsely ascribed to incidental ACJ OA, and the probability that diagnosis of symptomatic ACJ OA and surgery to resect the ACJ offer only potential harm and no potential benefit seems notable. This systematic review identified ACJ OA as a common aspect of human aging creating a notable risk of base rate fallacy.
The primary limitation of this systematic review is the lack of standardization of age categories across studies, making it difficult to pool the data. The age categories did not contain equal numbers of individuals, which increases the risk of under or overestimating the prevalence in age categories with fewer individuals. Second, we are unable to assess the quality of cadaver dissections, and the assessment of outcome in the cadaver studies required expert consensus due to the nature of the specimens. Third, there are relatively few studies addressing prevalence of ACJ OA and associated symptoms.
The observation of increased prevalence of ACJ OA with age supports that this is a universal or nearly universal age-appropriate degenerative process. ACJ OA is a common incidental finding and unusually diagnosed as the source of shoulder symptoms.16,19,21 We need specific imaging findings associated with symptoms from ACJ OA to limit the risk of overdiagnosis and overtreatment associated with high-prevalence pathology and the results are inconsistent to date. One study comparing two distinct groups of 70 patients found that findings such as bone marrow edema, inferior joint distension, and indentation of the ACJ onto the supraspinatus muscle on MRI correlated with symptoms from ACJ OA (defined as having localized AC joint pain with activities that require cross-body adduction, ACJ tenderness, and positive cross-body adduction test on exam).22 In contrast, a study examining preoperative MRI scans of 50 shoulders that underwent distal clavicle excision for symptoms ascribed to ACJ OA and 48 shoulders having MRI for shoulder pain without signs or symptoms of ACJ OA found that 70% of shoulders with symptomatic ACJ OA did not have bone marrow edema on MRI.23 A study examining three-dimensional Computed Tomography (CT) reconstructions of AC joints found that a finding of the anterior and posterior borders of the acromion at least 3 mm anterior to the borders of the clavicle was 87% sensitive and 89% specific for symptomatic ACJ OA, defined as having ACJ tenderness and temporary pain relief with intra-articular injection.24 But it is not clear why joint translation was studied and needs to be confirmed by other studies. Finally, several studies suggest no benefit to resecting the acromioclavicular joint during surgery to close a rotator cuff defect, supporting a tactic of de-emphasizing the ACJ OA on imaging.25, 26, 27, 28
The notable base rate of asymptomatic ACJ OA is supported by several studies that did not assess prevalence by age and therefore were not included in this systematic review. One found that 44 of 48 (92%) asymptomatic shoulders had signs of osteoarthritis on MRI.23 Another study of 114 people that had MRI for shoulder pain without tenderness at the ACJ or pain with cross-body adduction and were found to have ACJ OA findings on MRI found that 7 years later only 11 patients (10%) had both continued shoulder pain as well as either ACJ tenderness or pain with adduction.29 Given that these patients were treated for shoulder pain and these tests can be unreliable and nonspecific, that is a very low number. It would be helpful to do a similar study in people with no shoulder pain.
The finding of this systematic review that ACJ OA is highly prevalent in cadaver specimens and asymptomatic shoulders, more so with advancing age, establishes a high base rate of disease that one can safely infer is generally well-accommodated. The potential for misattribution of shoulder pain to radiographic evidence of ACJ OA is therefore high. A recent Cochrane Review found that subacromial decompression for rotator cuff tendinopathy was not superior to simulated subacromial decompression for pain intensity, magnitude of capability, and health-related quality of life30 and clinical guidelines state that it should not be offered to patients.31 It is possible that this holds true for operative management of ACJ OA as well. A review of one surgeon's experience found that acromioplasty and acromioclavicular joint resection were the least effective operative procedures for alleviation of shoulder pain.31 Another recent study that evaluated the functional outcomes of nonoperative (4 studies) and operative (15 studies) treatment for symptomatic ACJ OA found similar results.32
ACJ OA is common, benign, often asymptomatic and at risk for overtreatment. Surgical options are not without their complications, including persistent pain or instability after clavicle resection. Radiographic evidence of ACJ OA in a patient with shoulder pain presents a clinical challenge as the likelihood of the pain being due to isolated ACJ OA is low compared to that of other shoulder pathologies. A comprehensive evaluation of potential etiologies is necessary prior to developing a management plan to avoid misattribution of the pain and harmful interventions.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflicts of interest/Competing interests
David Ring reports other from Skeletal Dynamics, other from Wright Medical, personal fees from Deputy Editor for Clinical Orthopaedics and Related Research, personal fees from Universities and Hospitals, personal fees from Lawyers, personal fees from Health Services and Resource Administration and Department of Justice, outside the submitted work. All other authors have no relevant financial or non-financial interests to disclose.
Ethics approval
This is a systematic review. The IRB of University of Texas at Austin has confirmed that no ethical approval is required.
Consent
This is a systematic review. There were no participants to consent.
CRediT authorship contribution statement
Ayane Rossano: Formal analysis, Investigation, Writing – original draft, Writing – review & editing, Visualization, Project administration. Nivethitha Manohar: Conceptualization, Methodology, Formal analysis, Investigation, Writing – original draft. Wouter J. Veenendaal: Investigation, Writing – review & editing, Visualization. Michel P.J. van den Bekerom: Conceptualization, Writing – review & editing, Supervision. David Ring: Conceptualization, Methodology, Writing – review & editing. Amirreza Fatehi: Methodology, Writing – review & editing, Supervision.
Acknowledgements
None.
Appendix B. Search Strategy Prevalence of Acromioclavicular Joint Osteoarthritis: systematic review
Database: PubMed.
Date of search: 6/22/2020.
Dates covered: 1976 to last date searched.
Strategy.
| MeSH term | Key Word |
|---|---|
| Acromioclavicular Joint | Acromioclavicular joint, ACJ, acromioclavicular arthritis |
| Osteoarthritis | Osteoarthritis, OA, degenerative joint disease |
| Radiography | Radiography, X-ray |
Results.
| Query | Items Found | |
|---|---|---|
| 1 | Search: (((acromioclavicular joint[MeSH Terms]) OR (acromioclavicular joint)) OR (ACJ)) OR (acromioclavicular arthritis) ((“acromioclavicular joint” [MeSH Terms] OR ((“acromioclavicular joint” [MeSH Terms] OR (“acromioclavicular” [All Fields] AND “joint” [All Fields])) OR “acromioclavicular joint” [All Fields])) OR “ACJ” [All Fields]) OR (“acromioclavicular” [All Fields] AND (((“arthritis” [MeSH Terms] OR “arthritis” [All Fields]) OR “arthritides” [All Fields]) OR “polyarthritides” [All Fields])) | 3192 |
| 2 | Search: (((osteoarthritis[MeSH Terms]) OR (osteoarthritis)) OR (OA)) OR (degenerative joint disease) ((“osteoarthritis” [MeSH Terms] OR ((“osteoarthritis” [MeSH Terms] OR “osteoarthritis” [All Fields]) OR “osteoarthritides” [All Fields])) OR “OA” [All Fields]) OR (((“osteoarthritis” [MeSH Terms] OR “osteoarthritis” [All Fields]) OR ((“degenerative” [All Fields] AND “joint” [All Fields]) AND “disease” [All Fields])) OR “degenerative joint disease” [All Fields]) | 108,134 |
| 3 | Search: ((((radiography"[MeSH Terms])) OR (radiography)) OR (X-ray) (“radiography” [MeSH Terms] OR ((((((“diagnostic imaging” [MeSH Subheading] OR (“diagnostic” [All Fields] AND “imaging” [All Fields])) OR “diagnostic imaging” [All Fields]) OR “radiography” [All Fields]) OR “radiography” [MeSH Terms]) OR “radiographies” [All Fields]) OR “radiography” [All Fields])) OR (((((“diagnostic imaging” [MeSH Subheading] OR (“diagnostic” [All Fields] AND “imaging” [All Fields])) OR “diagnostic imaging” [All Fields]) OR “x ray” [All Fields]) OR “x-rays” [MeSH Terms]) OR “x rays” [All Fields]) | 2,031,742 |
| 4 | 1 AND 2 AND 3 | 100 |
Database: SCOPUS.
Date of search: 6/22/2020.
Dates covered: 1977 to last date searched.
Strategy.
| Term | Key Words |
|---|---|
| Acromioclavicular Joint | Acromioclavicular joint, ACJ, acromioclavicular arthritis, Coracoacromial ligament |
| Osteoarthritis | Osteoarthritis, OA, degenerative joint disease, degenerative arthritis, Osteoarthrosis deformans, osteoarthrosis, arthrosis |
| Radiography | Radiography, diagnostic x-ray, x-ray |
Results.
| Query | Items Found | |
|---|---|---|
| 1 | (ALL ( acromioclavicular AND joint) OR ALL (acj) OR ALL (acromioclavicular AND arthritis) OR ALL (coracoacromial AND ligament) ) | 8455 |
| 2 | (ALL ( osteoarthritis) OR ALL (OA) OR ALL (degenerative AND joint AND disease) OR ALL (degenerative AND arthritis) OR ALL (osteoarthrosis AND deformans) OR ALL (osteoarthrosis) OR ALL (arthrosis) ) | 501,462 |
| 3 | (ALL ( radiography) OR ALL (diagnostic AND x-ray) AND ALL (x-ray) ) | 485,508 |
| 4 | #1 AND #2 AND #3 | 168 |
Database: PubMed.
Date of search: January 11, 2021.
Dates covered: 1976 to last date searched.
Strategy.
| MeSH term | Key Word |
|---|---|
| Acromioclavicular Joint | Acromioclavicular joint, ACJ, acromioclavicular arthritis |
| Osteoarthritis | Osteoarthritis, OA, degenerative joint disease |
| Diagnostic imaging | Radiography, MRI, CT, ultrasound. |
Results.
| Query | Items Found | |
|---|---|---|
| 1 | Search: (((acromioclavicular joint [MeSH Terms]) OR (acromioclavicular joint)) OR (ACJ)) OR (acromioclavicular arthritis) ((“acromioclavicular joint” [MeSH Terms] OR ((“acromioclavicular joint” [MeSH Terms] OR (“acromioclavicular” [All Fields] AND “joint" [All Fields])) OR “acromioclavicular joint” [All Fields])) OR “ACJ" [All Fields]) OR (“acromioclavicular” [All Fields] AND (((“arthritis” [MeSH Terms] OR “arthritis” [All Fields]) OR “arthritides” [All Fields]) OR “polyarthritides” [All Fields])) | 3367 |
| 2 | Search: (((osteoarthritis [MeSH Terms]) OR (osteoarthritis)) OR (OA)) OR (degenerative joint disease) ((“osteoarthritis” [MeSH Terms] OR ((“osteoarthritis” [MeSH Terms] OR “osteoarthritis” [All Fields]) OR “osteoarthritides” [All Fields])) OR “OA” [All Fields]) OR (((“osteoarthritis” [MeSH Terms] OR “osteoarthritis” [All Fields]) OR ((“degenerative” [All Fields] AND “joint” [All Fields]) AND “disease” [All Fields])) OR “degenerative joint disease” [All Fields]) | 114,332 |
| 3 | Search: (Diagnostic imaging [MeSH Terms]) OR (diagnostic imaging) “diagnostic imaging” [MeSH Terms] OR (“diagnostic imaging” [MeSH Subheading] OR (“diagnostic” [All Fields] AND “imaging” [All Fields]) OR “diagnostic imaging” [All Fields] OR “diagnostic imaging” [MeSH Terms] OR (“diagnostic” [All Fields] AND “imaging” [All Fields])) | 2,782,770 |
| 4 | 1 AND 2 AND 3 | 110 |
Appendix C. Risk of bias and methodological quality of the included studies
| Bias | Possible outcomes | Frisch | Gumina | Nicholson | Needell | Liou | Stein | Bonsell | Pennington | Petersson | Eriks-Hoogland |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Selection | |||||||||||
| Representativeness of study sample |
|
C | B | A | C | C | C | C | A | A | A |
| Age determination |
|
C | C | D | B | B | A | B | A | D | A |
| Prevalence | |||||||||||
| Assessment of ACJ OA |
|
B | C | C | A | A | A | A | A | C | A |
| Definition/classification of ACJ OA |
|
A | B | B | B | C | A | A | B | A | A |
| Total Stars: | # stars awarded: 1 = low, 2–3 = moderate, 4 = high quality | 2 | 2 | 2 | 3 | 2 | 3 | 3 | 4 | 2 | 4 |
Adapted from Hoy et al. and the Newcastle-Ottowa Scale.
References
- 1.Teece R.M., Lunden J.B., Lloyd A.S., Kaiser A.P., Cieminski C.J., Ludewig P.M. Three-dimensional acromioclavicular joint motions during elevation of the arm. J Orthop Sports Phys Ther. 2008 Apr;38(4):181–190. doi: 10.2519/jospt.2008.2386. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Brown J.N., Roberts S.N., Hayes M.G., Sales A.D. Shoulder pathology associated with symptomatic acromioclavicular joint degeneration. J Shoulder Elbow Surg. 2000 May 1;9(3):173–176. [PubMed] [Google Scholar]
- 3.Velanovich V. Bayesian analysis in the diagnostic process. Am J Med Qual. 1994 Dec;9(4):158–161. doi: 10.1177/0885713X9400900405. [DOI] [PubMed] [Google Scholar]
- 4.Bossuyt P.M., Reitsma J.B., Linnet K., Moons K.G. Beyond diagnostic accuracy: the clinical utility of diagnostic tests. Clin Chem. 2012 Dec 1;58(12):1636–1643. doi: 10.1177/0885713X9400900405. [DOI] [PubMed] [Google Scholar]
- 5.Mall N.A., Foley E., Chalmers P.N., Cole B.J., Romeo A.A., Bach B.R., Jr. Degenerative joint disease of the acromioclavicular joint: a review. Am J Sports Med. 2013 Nov;41(11):2684–2692. doi: 10.1177/0363546513485359. [DOI] [PubMed] [Google Scholar]
- 6.Janssen S.J., Teunis T., Ring D., Parisien R.C. Cognitive biases in orthopaedic surgery. J Am Acad Orthop Surg. 2021 Jul 15;29(14):624–633. doi: 10.5435/JAAOS-D-20-00620. [DOI] [PubMed] [Google Scholar]
- 7.Moher D., Liberati A., Tetzlaff J., Altman D.G., PRISMA Group Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009 Aug 18;151(4):264–269. doi: 10.1371/journal.pmed.1000097. [DOI] [PubMed] [Google Scholar]
- 8.Ouzzani M., Hammady H., Fedorowicz Z., Elmagarmid A. Rayyan—a web and mobile app for systematic reviews. Syst Rev. 2016 Dec;5(1):1. doi: 10.1186/s13643-016-0384-4. 0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Hoy D., Brooks P., Woolf A., et al. Assessing risk of bias in prevalence studies: modification of an existing tool and evidence of interrater agreement. J Clin Epidemiol. 2012 Sep 1;65(9):934–939. doi: 10.1016/j.jclinepi.2011.11.014. [DOI] [PubMed] [Google Scholar]
- 10.Wells GA, Shea B, O'Connell D, Peterson J, Welch V, Losos M, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses, http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp (accessed 27 November 2020).
- 11.Petersson C.J. Degeneration of the acromioclavicular joint: a morphological study. Acta Orthop Scand. 1983 Jan 1;54(3):434–438. doi: 10.3109/17453678308996597. [DOI] [PubMed] [Google Scholar]
- 12.Fritsch K.O., Hamoud H., Allam A.H., et al. The orthopedic diseases of ancient Egypt. Anat Rec. 2015 Jun;298(6):1036–1046. doi: 10.1002/ar.23136. [DOI] [PubMed] [Google Scholar]
- 13.Gumina S., Salvatore M.D., De Santis P., Orsina L., Postacchini F. Coracoclavicular joint: osteologic study of 1020 human clavicles. J Anat. 2002 Dec;201(6):513–519. doi: 10.1046/j.1469-7580.2002.00115.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Nicholson G.P., Goodman D.A., Flatow E.L., Lu Bigliani. The acromion: morphologic condition and age-related changes. A study of 420 scapulas. J Shoulder Elbow Surg. 1996 Jan 1;5(1) doi: 10.1016/s1058-2746(96)80024-3. 1-1. [DOI] [PubMed] [Google Scholar]
- 15.Bonsell S., Pearsall Iv A.W., Heitman R.J., Helms C.A., Major N.M., Speer K.P. The relationship of age, gender, and degenerative changes observed on radiographs of the shoulder in asymptomatic individuals. J Bone Jt Surg Br Vol. 2000 Nov;82(8):1135–1139. doi: 10.1302/0301-620x.82b8.10631. [DOI] [PubMed] [Google Scholar]
- 16.Pennington R.G., Bottomley N.J., Neen D., Brownlow H.C. Radiological features of osteoarthritis of the acromioclavicular joint and its association with clinical symptoms. J Orthop Surg. 2008 Dec;16(3):300–302. doi: 10.1177/230949900801600306. [DOI] [PubMed] [Google Scholar]
- 17.Eriks-Hoogland I., Engisch R., Brinkhof M.W., Van Drongelen S. Acromioclavicular joint arthrosis in persons with spinal cord injury and able-bodied persons. Spinal Cord. 2013 Jan;51(1):59–63. doi: 10.1038/sc.2012.89. [DOI] [PubMed] [Google Scholar]
- 18.Liou J.T., Wilson A.J., Totty W.G., Brown J.J. The normal shoulder: common variations that simulate pathologic conditions at MR imaging. Radiology. 1993 Feb;186(2):435–441. doi: 10.1148/radiology.186.2.8421747. [DOI] [PubMed] [Google Scholar]
- 19.Needell S.D., Zlatkin M.B., Sher J.S., Murphy B.J., Uribe J.W. MR imaging of the rotator cuff: peritendinous and bone abnormalities in an asymptomatic population. AJR (Am J Roentgenol) 1996 Apr;166(4):863–867. doi: 10.2214/ajr.166.4.8610564. [DOI] [PubMed] [Google Scholar]
- 20.Stein B.E., Wiater J.M., Pfaff H.C., Lu Bigliani, Levine W.N. Detection of acromioclavicular joint pathology in asymptomatic shoulders with magnetic resonance imaging. J Shoulder Elbow Surg. 2001 May 1;10(3):204–208. doi: 10.1067/mse.2001.113498. [DOI] [PubMed] [Google Scholar]
- 21.Choo H.J., Lee S.J., Kim J.H., et al. Can symptomatic acromioclavicular joints be differentiated from asymptomatic acromioclavicular joints on 3-T MR imaging? Eur J Radiol. 2013 Apr 1;82(4):e184–e191. doi: 10.1016/j.ejrad.2012.10.027. [DOI] [PubMed] [Google Scholar]
- 22.Veen E.J., Donders C.M., Westerbeek R.E., Derks R.P., Landman E.B., Koorevaar C.T. Predictive findings on magnetic resonance imaging in patients with symptomatic acromioclavicular osteoarthritis. J Shoulder Elbow Surg. 2018 Aug 1;27(8):e252–e258. doi: 10.1016/j.jse.2018.01.001. [DOI] [PubMed] [Google Scholar]
- 23.Singh B., Gulihar A., Bilagi P., et al. Magnetic resonance imaging scans are not a reliable tool for predicting symptomatic acromioclavicular arthritis. Shoulder Elbow. 2018 Oct;10(4):250–254. doi: 10.1177/1758573217724080. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Bulkmans K., Peeters I., De Wilde L., Van Tongel A. The relationship of the acromion to the distal clavicle in normal and symptomatic degenerated acromioclavicular joints. Arch Orthop Trauma Surg. 2020 Apr;140(4):465–472. doi: 10.1007/s00402-019-03258-9. [DOI] [PubMed] [Google Scholar]
- 25.Chalmers P.N., Granger E., Ross H., Burks R.T., Tashjian R.Z. Preoperative factors associated with subsequent distal clavicle resection after rotator cuff repair. Orthop J Sports Med. 2019 May 2;7(5) doi: 10.1177/2325967119844295. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Livingstone A., Asaid R., Moaveni A.K. Is routine distal clavicle resection necessary in rotator cuff repair surgery? A systematic review and meta-analysis. Shoulder Elbow. 2019 May;11(1_suppl):39–45. doi: 10.1177/1758573217741124. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Métais P., Gallinet D., Labattut L., et al. Increased T2 signal intensity in the distal clavicle does not justify acromioclavicular resection arthroplasty during rotator cuff repair. J Orthop Traumatol: Surg Res. 2020 Dec 1;106(8):S217–S222. doi: 10.1016/j.otsr.2020.08.010. [DOI] [PubMed] [Google Scholar]
- 28.Wang J., Ma J.X., Zhu S.W., Jia H.B., Ma X.L. Does distal clavicle resection decrease pain or improve shoulder function in patients with acromioclavicular joint arthritis and rotator cuff tears? A meta-analysis. Clin Orthop Relat Res. 2018 Dec;476(12):2402. doi: 10.1097/CORR.0000000000000424. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Frigg A., Song D., Willi J., Freiburghaus A.U., Grehn H. Seven-year course of asymptomatic acromioclavicular osteoarthritis diagnosed by MRI. J Shoulder Elbow Surg. 2019 Oct 1;28(10):e344–e351. doi: 10.1016/j.jse.2019.04.004. [DOI] [PubMed] [Google Scholar]
- 30.Karjalainen T.V., Jain N.B., Page C.M., et al. Subacromial decompression surgery for rotator cuff disease. Cochrane Database Syst Rev. 2019;(1) doi: 10.1002/14651858.CD005619.pub3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Vandvik P.O., Lähdeoja T., Ardern C., et al. Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline. BMJ. 2019 Feb 6:364. doi: 10.1136/bmj.l294. [DOI] [PubMed] [Google Scholar]
- 32.Soler F., Mocini F., Djemeto D.T., Cattaneo S., Saccomanno M.F., Milano G. No differences between conservative and surgical management of acromioclavicular joint osteoarthritis: a scoping review. Knee Surg Sports Traumatol Arthrosc. 2021 Jul;29(7):2194–2201. doi: 10.1007/s00167-020-06377-8. [DOI] [PubMed] [Google Scholar]