ABSTRACT
PURPOSE: Anismus is a functional disorder featuring obstructive symptoms and paradoxical contractions of the pelvic floor. This study aims to establish diagnosis agreement between physiology and radiology, associate anismus with morphological outlet obstruction, and explore the role of sphincteric pressure and rectal volumes in the radiological diagnosis of anismus. METHODS: Consecutive patients were evaluated by using magnetic resonance imaging proctography/fluoroscopic defecography and anorectal physiology. Morphological radiological features were associated with physiology tests. A categorical analysis was performed using the chi-square test, and agreement was assessed via the kappa coefficient. A Mann-Whitney test was used to assess rectal volumes and sphincterial pressure distributions between groups of patients. A P-value of <0.05 was significant. RESULTS: Forty-three patients (42 female patients) underwent anorectal physiology and radiology imaging. The median age was 54 years (interquartile range, 41.5-60 years). Anismus was seen radiologically and physiologically in 18 (41.8%) and 12 patients (27.9%), respectively. The agreement between modalities was 0.298 (P = 0.04). Using physiology as a reference, radiology had positive and negative predictive values of 44% and 84%, respectively. Rectoceles, cystoceles, enteroceles and pathological pelvic floor descent were not physiologically predictive of animus (P > 0.05). The sphincterial straining pressure was 71 mmHg in the anismus group versus 12 mmHg. Radiology was likely to identify anismus when the straining pressure exceeded 50% of the resting pressure (P = 0.08). CONCLUSION: Radiological techniques detect pelvic morphological abnormalities, but lead to overdiagnoses of anismus. No proctographic pathological feature predicts anismus reliably. A stronger pelvic floor paradoxical contraction is associated with a greater likelihood of detection by proctography.
ABSTRACT
With an annual incidence greater than 65,000 in the United Kingdom, hip fractures are a common but debilitating injury predominantly affecting those over 65. Treatment is based on the anatomical location of the fracture relative to the capsule of the hip joint - fractures occurring within it are treated by arthroplasty, while extracapsular fractures are an indication for fixation. Intertrochanteric fractures are further grouped as stable (AO/OTA 31A1/A2) or unstable (31A3) which in turn governs in the current UK guidelines whether this fixation is achieved with a dynamic hip screw or intramedullary device. Anecdotally, some units are tending towards intramedullary devices for 31A2 fractures as well, a practice which from the evidence does not appear to confer benefit and carries an excess cost. We reviewed our data submitted to the National Hip Fracture Database over the last five years and identified all intertrochanteric fractures, from which cohort we identified all patients with 31A2 fractures by review of radiographs. The cohort comprised 370 patients. We then recorded age, gender, ASA grade, abbreviated mental test score, residence from where admitted, length of stay, destination on discharge and whether any further operations were required. There was no significant difference in the demographics of the groups, year-on-year, except gender mix. There was a significant, twenty-fold rise in the use of intramedullary devices between 2011 and 2015. Length of stay, length of overall episode of care, revision rates, mortality and destination on discharge were unchanged. This use is not supported by NICE guidelines and this study offers no evidence to contradict this position. We advocate all centres examine their practice to avoid a costly intervention without clinical benefit.
