Comparison of Cross-Sectional Area of Pubovisceral Muscle in Nulliparous and Primiparous Women.

INTRODUCTION AND HYPOTHESIS: The main risk factor for pelvic floor disorders is vaginal delivery, which may cause levator ani muscle (LAM) injury and denervation. LAM includes pubovisceral muscle (PVM, pubococcygeus), puborectalis muscle (PRM), and iliococcygeus muscle. We hypothesize that primiparous women with low pelvic floor muscle contraction have a reduced PVM cross-sectional area (CSA) compared to nulliparous women. METHODS (SAMPLE SIZE AND STATISTICAL APPROACHES): This single-centre prospective observational study compared healthy nulliparous (n = 40) to primiparous (n = 40) women after vaginal delivery without LAM avulsion and Oxford score ≤ 3. Demographics, questionnaires (ICIQ-UI-SF, OAB-Q-SF, PISQ-12), POP-Q, Oxford score, ultrasound measurements (minimal anteroposterior and lateral diameters, hiatal area, PRM thickness, levator-urethra gap) and magnetic resonance imaging (MRI)-PVM CSA were evaluated. Normality was tested, and an appropriate test was used to compare the groups. Power calculation suggested 40 participants per group. RESULTS: The primiparous group was older, had a higher BMI, and their hiatal area on ultrasound at contraction was larger compared to the nulliparous group. The CSA of the left-sided PVM (1.15 ± 0.50 cm2) was larger compared to the right side (1.03 ± 0.50 cm2), p = 0.02 in nulliparous women. The PVM CSA of primiparous women with low Oxford score was reduced compared to nulliparous (0.87 ± 0.30 versus 1.09 ± 0.50 cm2, p = 0.006). The intra-rater reliability for PVM CSA had an ICC of 0.90 and inter-rater ICC of 0.77. CONCLUSIONS: Primiparous women after vaginal delivery with low pelvic floor contraction force had reduced PVM CSA on MRI images compared to nulliparous women.

Three-Dimensional Transperineal Ultrasound Assessment of the Anal Sphincter Immediately After Vaginal Birth: An Exploratory Study.

OBJECTIVES: To assess the feasibility of acquiring adequate transperineal ultrasound (TPUS) volumes of the anal sphincter (AS) immediately after vaginal birth, the reproducibility of its measurements, and detecting defects therein. METHODS: Secondary analysis of TPUS volumes of the AS, acquired immediately after vaginal birth with a transversely oriented convex probe. Two independent experts ranked off-line image quality as "inadequate," "adequate," or "ideal" using the Point-of-Care Ultrasound Image Quality scale. On "adequate" and "ideal" quality volumes, the length of the external AS at 6 and 12 o'clock, and the volume of the external and internal AS were measured. Additionally, volumes were screened for AS defects on tomographic ultrasound imaging. Subsequently, we rated the intra- and interrater agreement on those findings. RESULTS: Of 183 volumes, 162 were considered "adequate" or of "ideal" quality (88.5%). Reasons for "inadequacy" were shadow artifacts (16/21), poor resolution (3/21), incomplete acquisition (1/21), or aberrant AS morphology (1/21). The intrarater reliability of two-dimensional (2D) and three-dimensional (3D) measurements was excellent, whereas interrater reliability was fair to good for 2D measurements and good for 3D measurements. In those tomographic ultrasound imaging (TUI) sequences including AS defects, the intra- and interrater reliability of the defect measurement were excellent [intraclass correlation coefficient (ICC) = 0.92 (0.80-0.94)] and moderate [ICC = 0.72 (0.63-0.79)]. In this cohort, there were only few (4/48; 8.3%) AS defects. However, grading them was poorly reproducible between experts. CONCLUSION: TPUS of the AS immediately after vaginal birth yields adequate image quality and allows for reproducible measurements. In the few patients with AS defects, there was good agreement on the presence, but it was poor for the extent of defects.

Anthropometry of the human calcaneus and orientation of the articular facet for the cuboid bone as a basis for anatomically correct positioning of osteosynthetic screws in fracture treatment.

PURPOSE: Fractures of the calcaneus are reported most commonly in the tarsal region. Their incidence is highest among active people in productive age. As such, optimal treatment can have vast implications for patients. The study aimed to compare calcaneal proportions of the Czech population in the last centuries to present day, for a precise choice and positioning of the osteosynthetic material, and its safe implantation in the anterior part of the calcaneus. Furthermore, we describe the frequency of the calcaneocuboid joint involvement in calcaneal fractures. METHODS: We obtained 69 macerated (dry) human calcanei from anatomical collections along with multiplanar reconstructions obtained from 43 serial CT scans from patients with injuries other than calcaneal fractures. Specimens were measured using a modified set of Bidmos et al. criteria (2006). Two groups (CT scans of macerated specimens and patients' CT scans) were statistically evaluated and compared with the help of an experienced statistician. Furthermore, scans of 80 surgically treated patients were retrospectively assessed for calcaneocuboid joint involvement. RESULTS: The median tilt of the calcaneocuboid joint in the transverse plane was 67° in the anatomical specimens and 72° in the multiplanar reconstructed CT scans taken from patients with intact tarsal regions. These results suggest that the length of screws should be ideally in the range between 21.3 and 25mm. In 47.3% of the patients presenting with a fractured calcaneus, the calcaneocuboid joint was involved. There was a statistically significant difference in most of the variables observed between the two groups. CONCLUSION: As the calcaneocuboid joint involvement appears to be present in up to 50% of cases, adequate care should be taken. To maximize the biomechanical properties of the construct and to minimize the risks, our findings suggest the screws should be at an inner tilt of 68-74° from the lateral calcaneal wall and be of 23.5-26.2mm length. However, due to differences between the two groups and the small sample size, further investigation is needed.