TO THE EDITOR:
In "Current Concepts Review. Subacromial Impingement Syndrome" (79-A: 1854—1868, Dec. 1997), Bigliani and Levine failed to mention arthrography of the shoulder as an imaging modality for the rotator cuff. The authors did mention the shortcomings of ultrasound in the detection of small tears of the rotator cuff and that ultrasound is less accurate overall than other imaging modalities. The authors discussed the fact that magnetic resonance imaging is gaining popularity. They admitted that it is difficult to differentiate between tendinitis of the rotator cuff and small tears of the rotator cuff on magnetic resonance images.
I find arthrography of the shoulder with the injection of air and contrast medium to be a minimally invasive test that is extremely accurate in the detection of full-thickness tears of the rotator cuff of any size. Arthrography is also much less costly than magnetic resonance imaging, which is inconclusive.
Gregory C. Sarkisian, D.O.: 11580 Lancaster Drive, Auburn, Ohio 44021
Dr. Bigliani and Dr. Levine reply:
We appreciate Dr. Sarkisian's comments regarding our article. We did not mention arthrography of the shoulder because it is not routinely used in most centers in North America.
Although some centers in Europe and the United States have had excellent results with arthrography, recent reports have shown that it is less reliable than magnetic resonance imaging and computed tomographic arthrography1-3. However, arthrography is certainly less expensive than magnetic resonance imaging and still plays a role in the diagnosis of tears of the rotator cuff at some centers.
Louis U. Bigliani, M.D.; William N. Levine, M.D.: New York Orthopaedic Hospital Associates, Incorporated, Columbia Presbyterian Medical Center, 161 Fort Washington Avenue, New York, N.Y. 10032