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© 1997 The Journal of Bone and Joint Surgery, Inc.
CorrespondenceTO THE EDITOR: "Arthrography of the Wrist. Assessment of the Integrity of the Ligaments in Young Asymptomatic Adults" (77-A: 1207–1209, Aug. 1995), by Kirschenbaum et al., presents interesting information. The authors are to be commended for the concept and design of their study. However, their interpretation of the data needs further discussion; we question whether the important message of this paper was presented clearly. Depending on the experience and bias of the reader, this article can be interpreted in one of two ways. A superficial interpretation is that, since asymptomatic defects are evident on arthrography, then arthrography has no value; unfortunately, the authors emphasized this interpretation, and, along with the Editorial Board of Reviewers, they missed the more important message of their study. The second interpretation, which is not as obvious to the casual or inexperienced reader, is that asymptomatic defects commonly occur and are revealed by a variety of diagnostic means (including arthrography, magnetic resonance imaging, and arthroscopy) but are clinically relevant only if a good clinical examination reveals a positive correlation. None of these diagnostic methods for showing communicating (or non-communicating) defects can demonstrate which defects are causing pain. Rather, the value of any of the methods is to confirm a clinical impression or to guide the surgeon's examination. Arthrography is no different in this regard than arthroscopy or magnetic resonance imaging. The same defects in the fourteen of the fifty-two asymptomatic wrists may have been apparent on a well performed magnetic resonance imaging study or with well executed arthroscopy. The problem is not the diagnostic tools but rather how the tools are used. By emphasizing the superficial interpretation, this article was more sensational but the more valid interpretation and message were clouded. We believe that the message of this paper should be that asymptomatic defects occur in the wrist, even in younger people. The community of physicians and surgeons who diagnose and evaluate painful wrists must search for methods to determine which ligamentous defects are important. Condemning arthrography for showing the defects is inappropriate. Condemn the surgeon for not using the arthrography (or arthroscopy or magnetic resonance imaging and so on) appropriately. Don't shoot the messenger.
Louis A. Gilula, M.D.; Paul R. Manske, M.D.; Yuming Yin, M.D.; William Shannon, Ph.D.: Washington University School of Medicine, 510 South Kingshighway Boulevard, St. Louis, Missouri 63110
Dr. Kirschenbaum, Dr. Sieler, Dr. Solonick, Dr. Loeb, and Dr. Cody reply: Dr. Gilula et al. believe that all of us misunderstood the important message of our own study. They also believe that the entire Editorial Board of Reviewers missed the message as well. We performed the study, accumulated the data, and reported the results. The final paragraph emphasizes what we think is the important message of our study: "The present report strongly suggests that the arthrogram should not be considered a definitive study for the diagnosis of a clinically important injury of a ligament in the wrist. The results of an arthrogram must be correlated with a thorough understanding of the history of the patient as well as with the findings of a careful clinical examination and other types of imaging." Is the interpretation of this statement any different than that proposed by Gilula et al. ("asymptomatic defects commonly occur and are revealed by a variety of diagnostic means ... but are clinically relevant only if a good clinical examination reveals a positive correlation")? The answer is no. A study similar to ours was performed on the lumbar spine to evaluate the prevalence of positive findings on magnetic resonance and computed tomography imaging in asymptomatic subjects1. More recently, the prevalence of tears of the rotator cuff in asymptomatic individuals was determined with magnetic resonance imaging5. Both of these studies emphasized the high prevalence of abnormal findings in asymptomatic individuals and the difficulty in making a decision to operate on the basis of a diagnostic test. In addition to the high prevalence of abnormal findings on arthrograms of the wrist, substantial rates of false-negative findings have been documented3,6. One study demonstrated a tear of the triangular fibrocartilage complex at the time of an operation in five of six patients who had had a negative arthrogram6. The issue of whether or not an arthrogram is useful in the treatment of an abnormality of the wrist is separate from, and should not be confused with, the results and conclusions of our article. We reported the prevalence of positive findings in asymptomatic individuals. We believe that the results of an arthrogram, positive or negative, rarely affect the over-all treatment. We also believe that clinical assessment by a skilled examiner is more sensitive and specific than arthrography for the diagnosis of clinically important ligament tears in the wrist and that arthrography adds little to the over-all treatment plan for most individuals. A prospective study is necessary to confirm our impressions. Incidentally, similar conclusions were made when the clinical value and cost-effectiveness of magnetic resonance imaging for disorders related to the knee were evaluated2, and the results of one study4 demonstrated that neither the diagnosis nor the treatment of common abnormalities of the shoulder was altered by the results of magnetic resonance imaging. We in no way condemn arthrography of the wrist. However, it should be made known that the prevalence of positive findings in asymptomatic individuals is quite high and that the decision to operate should be based on a precise clinical examination and not necessarily on the results of a diagnostic test.
David Kirschenbaum, M.D.; Shawn Sieler, M.D.: 1527 State Highway 27, Suite 1300, Somerset, New Jersey 08873
Douglas Solonick, M.D.; Debra M. Loeb, M.D.; Ronald P. Cody, Ed.D.: Departments of Radiology (D. S. and D. M. L.) and Environmental and Community Medicine (R. P. C.), University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, One Robert Wood Johnson Place, New Brunswick, New Jersey 08901
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