Musculoskeletal ultrasound: athletic injuries of the lower extremity

Athletic injuries of the lower extremities are commonly encountered in clinical practice. While some pathology can be diagnosed on physical exam, others are a clinical dilemma with nonspecific symptomatology. In these situations, ultrasound imaging can be utilized as an exceptional diagnostic tool, offering unique advantages over other imaging modalities. This article will review the imaging characteristics of commonly encountered athletic injuries of the lower extremity.

MR Imaging Appearances of Soft Tissue Flaps Following Reconstructive Surgery of the Lower Extremity

MR imaging appearances of different types of reconstructive muscle flaps following reconstructive surgery of the lower extremity with associated post-surgical changes due to altered anatomy, radiation, and potential complications, can be challenging. A multidisciplinary therapeutic approach to tumors allows for limb salvage therapy in a majority of the patients. Decision-making for specific types of soft tissue reconstruction is based on the body region affected, as well as the size and complexity of the defect. Hematomas and infections are early complications that can jeopardize flap viability. The local recurrence of a tumor within six months after a complete resection with confirmed tumor-free margins and adjuvant radiation therapy is rare. Identification of a new lesion similar to the initial tumor favors a finding of tumor recurrence.

Evaluation of Tumor Angiogenesis with a Second-Generation US Contrast Medium in a Rat Breast Tumor Model

OBJECTIVE: Tumor angiogenesis is an important factor for tumor growth, treatment response and prognosis. Noninvasive imaging methods for the evaluation of tumor angiogenesis have been studied, but a method for the quantification of tumor angiogenesis has not been established. This study was designed to evaluate tumor angiogenesis in a rat breast tumor model by the use of a contrast-enhanced ultrasound (US) examination with a second-generation US contrast agent. MATERIALS AND METHODS: The alkylating agent 19N-ethyl-N-nitrosourea (ENU) was injected into the intraperitoneal cavity of 30-day-old female Sprague-Dawley rats. Three to four months later, breast tumors were detected along the mammary lines of the rats. A total of 17 breast tumors larger than 1 cm in nine rats were evaluated by gray-scale US, color Doppler US and contrast-enhanced US using SonoVue. The results were recorded as digital video images; time-intensity curves and hemodynamic parameters were analyzed. Pathological breast tumor specimens were obtained just after the US examinations. The tumor specimens were stained with hematoxylin and eosin (H & E) and the expression of CD31, an endothelial cell marker, was determined by immunohistochemical staining. We also evaluated the pathological diagnosis of the tumors and the microvessel density (MVD). Spearman's correlation and the Kruskal-Wallis test were used for the analysis. RESULTS: The pathological diagnoses were 11 invasive ductal carcinomas and six benign intraductal epithelial proliferations. The MVD did not correlate with the pathological diagnosis. However, blood volume (BV) showed a statistically significant correlation with MVD (Spearman's correlation, p < 0.05). CONCLUSION: Contrast-enhanced US using a second-generation US contrast material was useful for the evaluation of tumor angiogenesis of breast tumors in the rat.

Diagnostic Value of Dynamic Perfusion MR Imaging in Benign and Malignant Musculoskeletal Lesions

PURPOSE: To assess the diagnostic value of dynamic perfusion MR imaging for differentiation between benign and malignant musculoskeletal lesions. MATERIALS AND METHODS: Dynamic perfusion MR imaging was performed using a 3.0 T system in 32 female and 30 male patients (aged 10-90 years, mean age, 43 years). Following the assessment of the precontrast imaging, a dynamic study was performed. This dynamic technique allowed for 638 images to be obtained at 11 levels throughout the lesion. Twenty-eight lesions originated within bone (8 benign, 20 malignant), whereas 34 lesions were of soft tissue origin (22 benign, 12 malignant). The final diagnosis was histopathologically confirmed in all patients. To differentiate between benign and malignant lesions, we analyzed the four parameters: (maximal relative enhancement (MRE), time to peak (TTP), wash in rate (WI), steepest slope (SS) and the distribution of time intensity curve (TIC) patterns. RESULTS: The TTP, WI, and SS values of malignant lesions were statistically significant from those of benign lesions (p < 0.05). However, the difference for the MRE values was not statistically significant. The distribution of TIC patterns was a helpful indicator of benign or malignant state, however the difference between the two states was not significant. CONCLUSION: Dynamic perfusion MR imaging is a helpful tool in differentiating benign and malignant musculoskeletal lesions.

Mucoid Degeneration of Anterior Cruciate Ligament: Correlation between MR Imaging and Pathologic Findings in Patients with Osteoarthritis of the Knee

PURPOSE: To evaluate the mucoid degeneration (MD) of the anterior cruciate ligament (ACL) of the knee by correlation of MRI findings with pathology, in the patients with osteoarthritis (OA). MATERIALS AND METHODS: This study included 17 patients (mean 68.8 years old) who underwent preoperative MRI. In proton density-weighted sagittal and coronal images ACLs were evaluated for the thickness and signal intensity (SI). Total knee replacement arthroplasty was performed and the pathologic findings of ACL were evaluated. MD was classified as 3 grades according to the degenerated amount in microscopy. Thickness and SI was evaluated as normal or increased on MRI. RESULTS: All of the 4 patients who showed thickened ACL showed increased SI on MRI. All of the 8 patients with increased SI of the ACL on MRI had MD in the ACL. However, remained 9 patients also had MD, in spite of their normal thickness and SI on MRI. Calcification was seen in 5 patients. CONCLUSION: Eight cases who showed ACL thickening or increased SI on MRI were well correlated with MD, however, because the other nine cases who showed normal thickness and normal SI of ACL on MRI also showed MD in pathology, normal MRI finding should not exclude the possibility of MD of ACL.

Naviculo-Medial Cuneiform Coalition: Radiological Features

PURPOSE: To define the radiological features of the naviculo-medial cuneiform coalition. MATERIALS AND METHODS: This study examined 35 feet from 25 patients (mean age 26 years) with a naviculo-medial cuneiform coalition. The images were analyzed retrospectively with regard to irregular articular surface, subchondral sclerosis, subchondral cyst, beak-like spur, the change in joint space, bony fusion seen on plain radiographs (n=35) and CT (n=14), and the histological type of coalition on MRI (n=3). The extent of joint involvement was also evaluated. RESULTS: Of the 35 feet, plain radiographs and/or CT showed an irregular articular surface in 34 (97.1%), subchondral sclerosis in 30 (85.7%), a subchondral cyst in 29 (82.9%), a beak-like spur in 23 (65.7%), a narrowing of the joint space in 24 (68.6%) and no bony fusions (0%). The T1-weighted images revealed low signal intensity, and the T2-weighted fast spin-echo and gradient images revealed high signal intensity in the three feet with a cartilaginous coalition. The coalition involved the plantar part of the joint in all 35 feet. CONCLUSION: The characteristic radiological features of a naviculo-medial cuneiform coalition include an irregular articular surface with possible secondary degenerative changes in the plantar margin of the joint, non-osseous type.

Non-Contiguous Spinal Injury in Cervical Spinal Trauma: Evaluation with Cervical Spine MRI

OBJECTIVE: We wished to evaluate the incidence of non-contiguous spinal injury in the cervicothoracic junction (CTJ) or the upper thoracic spines on cervical spinal MR images in the patients with cervical spinal injuries. MATER AND METHODS: Seventy-five cervical spine MR imagings for acute cervical spinal injury were retrospectively reviewed (58 men and 17 women, mean age: 35.3, range: 18-81 years). They were divided into three groups based on the mechanism of injury; axial compression, hyperflexion or hyperextension injury, according to the findings on the MR and CT images. On cervical spine MR images, we evaluated the presence of non-contiguous spinal injury in the CTJ or upper thoracic spine with regard to the presence of marrow contusion or fracture, ligament injury, traumatic disc herniation and spinal cord injury. RESULTS: Twenty-one cases (28%) showed CTJ or upper thoracic spinal injuries (C7-T5) on cervical spinal MR images that were separated from the cervical spinal injuries. Seven of 21 cases revealed overt fractures in the CTJs or upper thoracic spines. Ligament injury in these regions was found in three cases. Traumatic disc herniation and spinal cord injury in these regions were shown in one and two cases, respectively. The incidence of the non-contiguous spinal injuries in CTJ or upper thoracic spines was higher in the axial compression injury group (35.3%) than in the hyperflexion injury group (26.9%) or the hyperextension (25%) injury group. However, there was no statistical significance (p > 0.05). CONCLUSION: Cervical spinal MR revealed non-contiguous CTJ or upper thoracic spinal injuries in 28% of the patients with cervical spinal injury. The mechanism of cervical spinal injury did not significantly affect the incidence of the non-contiguous CTJ or upper thoracic spinal injury.

Non-Infectious Ischiogluteal Bursitis: MRI Findings

OBJECTIVE: We wished to report on the MRI findings of non-infectious ischiogluteal bursitis. MATER AND METHODS: The MRI findings of 17 confirmed cases of non-infectious ischiogluteal bursitis were analyzed: four out of the 17 cases were confirmed with surgery, and the remaining 13 cases were confirmed with MRI plus the clinical data. RESULTS: The enlarged bursae were located deep to the gluteus muscles and postero-inferior to the ischial tuberosity. The superior ends of the bursal sacs abutted to the infero-medial aspect of the ischial tuberosity. The signal intensity within the enlarged bursa on T1-weighted image (WI) was hypo-intense in three cases (3/17, 17.6%), iso-intense in 10 cases (10/17, 58.9%), and hyper-intense in four cases (4/17, 23.5%) in comparison to that of surrounding muscles. The bursal sac appeared homogeneous in 13 patients (13/17, 76.5%) and heterogeneous in the remaining four patients (4/17, 23.5%) on T1-WI. On T2-WI, the bursa was hyper-intense in all cases (17/17, 100%) ; it was heterogeneous in 10 cases and homogeneous in seven cases. The heterogeneity was variable depending on the degree of the blood-fluid levels and the septae within the bursae. With contrast enhancement, the inner wall of the bursae was smooth (5/17 cases), and irregular (12/17 cases) because of the synovial proliferation and septation. CONCLUSION: Ischiogluteal bursitis can be diagnosed with MRI by its characteristic location and cystic appearance.

Diagnostic Value of Ultrasonography for Acute Tear of Tibiofibular Syndesmosis in Ankle / 대한족부족관절학회지

PURPOSE: We studied the diagnostic value of ultrasonography to confirm the presence of the syndesmosis injuries in the ankle. MATERIALS AND METHODS: Pre-operative ultrasonography were taken in 42 cases of ankle fractures to determine injury of syndesmosis between February 2000 and August 2003. Tear of syndesmosis was confirmed when they met the following criteria; widening of distal tibiofibular clear space greater than 7 mm on pre-operative AP X-rays, leakage of contrast dye during intra-operative arthrography, and operative findings revealing syndesmosis rupture. We compared these diagnoses with those made by pre-operative ultrasonography. RESULTS: Syndesmosis injuries were confirmed in 23 cases among the total 42 cases. Ultrasonography revealed syndesmosis tear in 25 cases, with 20 cases corresponding with confirmed tear and 5 cases without tear in confirm. Syndesmoses were found to be intact in 17 cases of ultrasonograph, but 3 cases were actually confirmed tear. In ankle ultrasonography, the sensitivity was 90.9%, the specificity was 75.0%. CONCLUSION: Preoperative ultrasonography is a non-invasive and useful study to determine the syndesmosis injury in ankle fractures.

MR Findings of Chondroblastoma with Emphasis on Enhancement Pattern

PURPOSE: To analyze the MR findings of chondroblastoma and peritumoral bone marrow, focussing on the enhancement pattern. MATERIALS AND METHODS: Enhanced MR images obtained from 23 patients with pathologically proven chondroblastoma were retrospectively reviewed by three radiologists. The enhancement pattern was classified as one of three types: homogeneous, heterogeneous, or peripheral rim, while peritumoral bone marrow enhancement was assigned one of four grades. Correlation between the enhancement pattern and T2 signal intensity of a tumor was analyzed by Fisher's exact test. RESULTS: The enhancement pattern was homogeneous in ten cases, heterogeneous in six, and involved the peripheral rim in seven. In 11 cases, peritumoral bone marrow enhancement was observed. Among the ten instances of homogeneous enhancement the signal intensity seen at T2WI was homogeneously iso or low in six cases, homogeneously high in two, and heterogeneous in two. Among the seven cases in which there was peripheral rim enhancement, the signal intensity observed at T2WI was homogeneously high in three, fluid-fluid level in three, and homogeneously iso or low in one. CONCLUSION: At MR imaging, chondroblastoma shows variable signal intensities and enhancement patterns. The peripheral rim enhancement observed at T2WI correlated with homogeneously high signal intensity or fluid-fluid levels.

The Diagnostic Usefulness of CT-guided Needle Biopsy or Aspiration in Infectious Spondylitis

PURPOSE: To determine the diagnostic value of CT-guided biopsy or aspiration of the spine and paraspinal soft tissue in infectious spondylitis. MATERIALS AND METHODS: Between January 2000 and June 2002, 58 patients underwent 67 biopsies and/or aspirations under CT guidance to identify the organism causing infectious spondylitis, and were included in this study. Nine underwent rebiopsy. In all patients, MR images were available before biopsy and/or aspiration. In 63 of 67 procedures, the specimens or aspirates obtained were prepared for culture and smear, and for histological examination, four procedures involved aspiration only. In ten patients with suspected tuberculosis, a polymerase chain reaction test was performed. For all procedures, the transpedicular, transcostovertebral or paravertebral route was involved, according to the level and shape of the lesions, and 14-, 16-, or 18-gauge core biopsy needles and/or 20-gauge aspiration needles were employed. Lesions invloved a paravertebral (n=17), psoas (n=8) or epidural (n=1) abscess; an intervertebral disc (n=20); or a vertebral body (n=21). The levels at the mid-thoracic spine were T4-T10 (n=11); at the thoracolumbar junction, T11-L1 (n=14); at the lumbar spine, L1-L4 (n=25); and at the lumbo-sacral junction, L5-S1 (n=17). In nine of 58 patients, rebiopsy was performed. RESULTS: Diagnosis was confirmed in 22 of 58 patients (38%), and was as follows: tuberculous spondylitis (n=17), pyogenic spondylitis (n=4), and fungal spondylitis (n=1). Thirty-six unconfirmed cases were diagnosed as nonspecific inflammation (n=21), fibrosis involving cortical bone (n=1), necrotic material (n=5) and inadequate specimen without evidence of malignancy (n=9). Only one of the nine cases in which biopsy was repeated was confirmed as tuberculous spondylitis. Diagnosis was confirmed in 7 of 17 paravertebral abscesses (41%), 8 of 21 vertebral bodies (38%), 6 of 20 intervertebral discs (30%) and 1 of 8 psoas abscesses (13%). CONCLUSION: In infectious spondylitis, the overall diagnostic yield of CT-guided needle biopsy and/or aspiration is relatively low, but the procedure seems to be effective for excluding malignancy. In identifying the organisms involved in infectious spondylitis, a paravertebral lesion is in a more favoured location than a psoas lesion.

MR Findings of Traumatic Transient Lateral Dislocation of the Patellae

PURPOSE: To determine the magnetic resonance (MR) imaging characteristics of traumatic transient lateral dislocation of the patellae. MATERIALS AND METHODS: In eight patients (6 males, 2 females, mean age: 22.4 years) in whom transient lateral dislocation of the patella was diagnosed, the distinctive MR imaging findings reflecting known injury mechanism were retrospectively analyzed with regard to bone contusion, chondral defect, fracture, loose body, joint effusion, and the associated soft tissue abnormalities. RESULTS: All of eight patients had bone contusions in the lateral femoral condyle and medial facet of the patella, while in five, chondral defects were present in this latter region. In three patients, fractures of the on lateral femoral condyle (n=2) and medial facet of the patella (n=3) were noted, and in three others, loose bodies were noted. Joint effusion [simple effusion (n=4), lipohemarthrosis (n=3)] was observed in seven patients, and associated soft tissue injuries [to the medial patellar retinaculum (n=8), patellar tendon (n=2), and anterior cruciate ligament (n=1)] in eight. Patellar subluxation was found in seven. CONCLUSION: MR imaging is a useful technique for the diagnosis of traumatic lateral dislocation of the patella. The significant MR findings are bone contusion in the lateral femoral condyle and medial facet of the patella, chondral defect, fracture, joint effusion, injury to the medial patellar retinaculum, and patellar subluxation.

Subtalar Coalition: Usefulness of the C Sign on Lateral Radiographs of the Ankle

PURPOSE: To assess the usefulness of the talocalcaneal C sign in the diagnosis of subtalar coalition, as seen on lateral radiographs of the ankle. MATERIALS AND METHODS: Lateral radiographs of 12 ankles in 11 patients were included in this study. Twelve subtalar coalitions were confirmed by surgery (n=6), or by CT and/or MR (n=6). The presence of the talocal-caneal C sign on lateral ankle radiographs was determined. RESULTS: The C sign was continuous in six feet and interrupted in the remaining six. Subtalar coalition occurred simultaneously in the middle and posterior subtalar joints in two cases, the posterior subtalar joint only in six, and in the middle subtalar joint only in four. In six cases confirmed at surgery, subtalar coalitions consisted of both synostosis and non-osseous fusion (synchondrosis and/or syndesmosis) and in one case of middle subtalar coalition, there was a bony bridge. The remaining six cases, confirmed at CT or MRI, involved both synostosis and non-osseous fusion (n=1) or non-osseous fusion only (n=5). CONCLUSION: In the diagnosis of subtalar coalition, the talocalcaneal C sign, seen on lateral radiographs of the ankle, is a useful indicator.

Detection of Synovial Hypertrophy in Idiopathic Carpal Tunnel Syndrome Using Ultrasongraphy / 대한정형외과학회잡지

OBJECTS: Synovial thickness in carpal tunnel was measured by high-resolution ultrasonography to evaluate the relation of synovial hypertrophy in idiopathic carpal tunnel syndrome. MATERIALS AND METHODS: Thickness of synovium of flexor tendons in 46 hands of idiopathic carpal tunnel syndrome and 50 hands of normal control were measured quantitatively by high-resolution ultrasonography. The patients were classified into three groups according to the clinical severity: Group I had typical clinical symptoms and positive provocation test (17 cases) , Group II had sensory decreation on the dermatome of median nerve (21 cases) , and Group III had sensory decreation and thenar muscle weakness. The thickness of flexor tendons in the three groups and control group were statistically compared. RESULTS: The mean value of thickness of carpal tunnel syndrome was 1.06mm and that of control group was 0.87mm (p=0.012) . Positive correlation was revealed according to the clinically classified three groups. CONCLUSION: Synovial hypertrophy in carpal tunnel has positive relationships with idiopathic carpal tunnel syndrome, and it reveal possibly the progression of the disease.

MR Imaging of Sacrococcygeal Pilonidal Sinus

PURPOSE: The purpose of this study is to evaluate the characteristic MR findings of sacrococcygeal pilonidal sinus. MATERIALS AND METHODS: Eight MR images of pathologically proven sacrococcygeal pilonidal sinus were retrospectively reviewed [M: F = 7: 1; age range 9-41 (median, 17) years]. In all cases, a sacrococcygeal mass was present. Five of the eight patients experienced pain, and in three was discharge. MR findings were evaluated with regard to the location and extent of the lesion, and the presence of sinus or cyst, and the results were compared with the pathologic findings. RESULT: According to the clinical manifestations, each case was assigned to one of four groups: the first type (n= 3) showed dermal thickening with subcutaneous fatty infiltration of the ipsilateral natal cleft while pathologically, a follicular cyst with dermal fibrosis and multiple fatty lobules with fibrous septa were found to be present. In the second type (n = 3), fluid was observed in the sinus tract, while the pathologic findings demonstrated the presence of an abscess in this area. In the third type (n = 1), a cystic lesion with airfluid level was present; pathologically, an abscess was revealed. The fourth type (n = 1) showed only a low signal intensity sinus tract on both T1 and T2-weighted images, while the pathologic findings indicated the presence of hairs and follicles within the tract. CONCLUSION: The MR findings of sacrococcygeal pilonidal sinus depend on the clinical manifestation and include subcutaneous fatty infiltration, a sinus tract with or without fluid retention, and a cystic lesion with air fluid level. These findings could be helpful for differentiating between this and other sacrococcygeal lesions.

Ganglionic Cysts Related to the Scapula: MR Findings

PURPOSE: To evaluate the magnetic resonance (MR) imaging characteristics of ganglionic cysts related to thescapula. MATERIAL AND METHOD: We retrospectively reviewed 15 ganglionic cysts diagnosed by MR imaging in 14pa-tients who subsequently underwent surgical excision (n=8) or needle aspiration (n=1). Five other patients whoselesion-related symptoms were not too severe to manage underwent conservative treatment. We ana-lyzed MR findingswith regard to the size, shape and presence of internal septa, the location and signal intensity of the lesion,and associated findings such as change of rotator cuff muscle, labral tear and bone erosion. We also evaluated thepresence of tear of rotator cuff tendon, tendinosis, and subacromial enthesophyte. RESULTS: The diameter ofganglionic cysts was 0.5 -5.5 (mean, 2.8)cm, and they were round (n=2), ovoid (n=6), or elongated (n=7). Whereinternal septa were present (n=13), cysts were lobulated. Lesions were located in both scapular and spinoglenoidnotches (n=9), only in the scapular notch (n=2), only in the spinoglenoid notch (n=2) or within the bone (n=2). Ineleven cases they were very close to the superoposterior aspect of the glenoid labrum (n=11). On T1-weightedimages, all lesions were seen to be iso- or hypointense to mus-cle, while on T2-weighted images, they werehyperintense, resembling joint fluid (n=14), except in one patient with hemorrhage. Associated findings were edemaof the infraspinatus muscle (n=4), pressure erosion of the scapular neck (n=1), and labral tear (n=1). A tornsupraspinatus tendon (n=2), supraspinatus tendinosis(n=3), and subacromial enthesophyte (n=2) were also present.CONCLUSION: MR imaging was helpful in diagnosing ganglionic cysts and detecting associated lesions.

Reconstruction of the Posterolateral Instability of the Knee / 대한정형외과학회잡지

PURPOSE: This study reports the results of a treatment for posterolateral instability of the knee with a modified Muller's method. MATERIALS AND METHODS: Fourteen patients (3 acute and 11 chronic cases) with a modified Muller's method and with a follow-up period of more than 12 months, average follow-up period of 15 months (range, 12 to 22 months) was included. We recorded and analysed the physical findings (reverse Lachmann test and varus stress test at 30 degree knee flexion), stress roentgenograms at preoperative 8 postoperative 12 months, magnetic resonance imagings and Lysholm score at preoperative, postoperative 3, 12 months and the last follow-up. RESULTS: Average Lysholm score was 65A preoperatively and 90.0 at postoperative 12 months. The posterolateral stabilities of the knee were improved in all cases postoperatively, according to the clinical stability tests (reverse Lachmann test and varus stress test at 30 degree knee flexion) and stress roentgenograms. CONCLUSIONS: Modified Muller's technique-the reconstruction of the popliteus tendon using iliotibial band-represents an excellent method to restore tension in the posterolateral complex of the acutely and chronically injured knee.

Language Lateralization by Functional MRI: A Comparison with Wada Test-preliminary Results

PURPOSE: To evaluate the usefulness of functional MR imaging (fMRI) for the determination of languagedomi-nance and to assess differences in language lateralization according to activation task or activated area. MATERIALS AND METHODS: Functional maps of the language area were obtained during word generation tasks (noun andverb) and a reading task in ten patients (9 right handed, 1 left handed) who had undergone the Wada test. MRexaminations were performed using a 1.5T scanner and the EPI BOLD technique. The SPM program was employed for thepostprocessing of images and the threshold for significance was set at p<0.001 or p<0.01. A lateralization indexwas calculated from the number of activated pixels in three hemispheric re-gions (whole hemisphere, frontal lobe,and temporoparietal lobe), and the results were compared with those of Wada tests. The results for lateralizationof language area were compared among stimulation tasks and regions and used for calculation of lateralizationindices. RESULTS: During the Wada test, nine patients were left dominant and one patient was right dominant forlan-guage. Language dominance based on activated signals in each hemisphere was consistent with the results of theWada test in 87.5% (verb and noun generation tasks) and 90% (reading task) of patients. Language domi-nancedetermined by activated signals in the frontal lobe was consistent in 87.5%, 75%, and 80% of patients in eachstimulation task (verb generation, noun generation, and reading), respectively. The consistency rate of ac-tivatedsignals in the temporoparietal lobe was 87.5%, 87.5% and 80% of patients in each task. The mean val-ue of thelateralization index, calculated on the basis of activated signals in the temporoparietal lobe was higher thanthat in the hemisphere or frontal lobe. The verb generation task showed a higher lateralization index than thenoun generation or reading task. CONCLUSION: The lateralization index was higher in the verb generation task andin the region of the tem-poroparietal lobe than in other stimulation tasks or regions. fMRI is a potentiallyuseful non-invasive method for the determination of language dominance.

A case of Diffuse Idiopathic Skeletal Hyperostosis (DISH) Presented with Idiopathic Hypoparathyroidism and Diabetes Mellitus / 대한류마티스학회지

Diffuse Idiopathic Skeletal Hyperostosis (DISH) is a skeletal disease characterized by ligamentous ossification of the anterolateral side of the spine. Paravertebral and ligamentous ossification appears to be an usual complication of hypoparathyroidism. Diabetes Mellitus has often been mentioned in associated with DISH. The patient was presented with back pain, stiffness and intermittent numbness of hands and feet. Spine X-ray showed extensive ligamentous ossification of the anterolateral side of the spine with normal disc space height. Sacroiliac joints are normal. Increased bone mineral density of the L-spine and femur neck was observed, as well. Hypocalcemia, hyperphophatemia and low intact parathyroid hormone level were detected. Postprandial sugar were elevated. HLA B27 was negative.

Ultrasonographic Evaluation of Ischial Bursitis

PURPOSE: The objective of this study was to evaluate the findings of ultrasonography (US) in patients withis-chial bursitis. MATERIALS AND METHODS: Our study included 27 patients (mean age 62 years) who underwent US fora painful mass or tenderness in the buttock area. In six of these 27, serous fluid was obtained by needleaspiration, and in five cases, bursal excision permitted histologic confirmation. The other sixteen patients werefollowed up for one or two months with only NSAID medication; all showed some improvement or remission of symptoms. Using a 5-10 MHz linear array probe, US examination was performed while the patient was lying facedown. US images were analyzed with regard to location and size of the lesions, thickness of cyst wall, thepres-ence of internal septa or mural nodules, echogenicity of the cyst wall, fluid content, internal septa,compressibility by a probe, and Doppler signals within the cyst wall. RESULTS: In all 27 patients, ischialbursitis was located superficially to ischial tuberosity. Lesion size(maximum diameter) was 1.5-7(mean 3.8)cm, andthe cyst wall was 0.2-0.8cm thick. Internal septa and mural nodules were seen in 12 cases (44%) and 13 cases(48%), respectively. The cyst wall was identifiable in 21 cases (78%), appearing as a single layer with lowechogenicity (n=10) or with high echogenicity (n=1); it also appeared as two (n=6) or three (n=4) layers ofdifferent echogenicities. When internal septa were present, fluid within the cyst was low echoic in 59% of cases,high echoic in 30%, and of mixed echogenicity (so-called compartmentalization) in 15%. In all cases, the cystbecame deformed, when compressed by a probe. In all patients who underwent doppler examination, some vascularitywas found within the cyst wall. CONCLUSION: US helped to detect ischial bursitis; US findings were thin-walled cystic lesion located superficially to ischial tuberosity, with or without internal septa and mural nodules, andeasy compressibility.