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1 Iwate Medical University School of Medicine Morioka 020-8505,
Japan
2 Akita University School of Medicine Akita 010-8543, Japan
We read with interest the paper by Dépelteau et al. titled "Arthrography of the Shoulder: A Simple Fluoroscopically Guided Approach for Targeting the Rotator Interval" [1] in a recent issue of the AJR.
Shoulder arthrography is currently not frequently performed because of the widespread use of MRI, but it is still a simple and inexpensive mode of assessing rotator cuff integrity. For such a purpose, avoiding puncture of the subacromial–subdeltoid bursae is important to eliminate a false-positive finding of rotator-cuff tear. Avoiding such a puncture is the main reason we have been following the conventional puncture technique aimed at the middle or lower third of the glenohumeral joint (the level overlying the glenoid of the scapula), not at the rotator interval.
The shape and extent of the subacromial–subdeltoid bursae are well described by means of subacromial bursography [2, 3].
The subacromial–subdeltoid bursae overlie the superior aspect of the rotator interval, and using the authors' rotator interval approach [1], the subacromial–subdeltoid bursae may be punctured. For the evaluation of adhesive capsulitis and shoulder instability, puncturing the subacromial–subdeltoid bursae will not affect the result, but it may not be appropriate for the evaluation of rotator-cuff tear.
In addition, we are concerned about the incidence of contrast extravasation after successful injection through loose connective tissue like the rotator interval rather than injection through the subscapularis muscle. We are particularly interested in these two potential drawbacks in the authors' technique.
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CHUM, Hôpital Saint-Luc Montreal, QC H2X 3J4, Canada
We appreciate the interest of Drs. Ehara, Itoi, and Sashi in our recent article [1], and we would like to address the issues raised.
In our practice, shoulder arthrography is still frequently performed. Although sonography and MRI have supplanted shoulder arthrography as a diagnostic method for assessment of rotator cuff tears, we still perform shoulder arthrography almost on a daily basis as part of CT arthrography and MR arthrography and for the treatment of adhesive capsulitis.
We agree that the subacromial–subdeltoid bursae cover a large surface area of the shoulder. They may extend to the coracoid process medially, and they extend to cover the bicipital groove anteriorly [2]. The subacromial–subdeltoid bursae are also located deep relative to the deltoid muscle and superficially to the subscapularis tendon and the rotator cuff interval. Hence, during shoulder arthrography using the anterior approach through the rotator cuff interval [1], the needle may traverse the subacromial–subdeltoid bursae but is advanced until it comes in contact with the humeral head. The contact with the humeral head provides a definite end point for the position of the needle and ensures its intraarticular position. We have been using this method of shoulder arthrography for many years, and direct iatrogenic contrast injection into the subacromial–subdeltoid bursae has never occurred.
Conversely, when the Schneider technique for shoulder arthrography is used, aiming at the junction of the middle and lower thirds of the glenohumeral joint, direct injection of the subcoracoid bursa may occur and has been reported as a cause of technical failure [2–4]. In addition, inadvertent injection of the subcoracoid bursa may result in a false diagnosis of complete rotator cuff tear, because the subcoracoid bursa may naturally communicate with the subacromial–subdeltoid bursae [2].
With regard to the third issue, in our experience contrast extravasation after successful shoulder arthrography targeting the rotator cuff interval does not occur unless the volume of contrast material injected surpasses the shoulder joint capacity. This occurs in cases of adhesive capsulitis, when distention arthrography is performed intentionally as part of the treatment. When the shoulder-joint capsule ruptures, extravasation of contrast material occurs at the subscapularis recess or biceps tendon sheath, not into the subacromial–subdeltoid bursae.
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