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Evaluation of Sexual Function Before and After Hip Arthroscopic Surgery for Symptomatic Femoroacetabular Impingement Simon Lee, Rachel M. Frank, Joshua Harris, Sang Hoon Song, Charles A. Bush-Joseph, Michael J. Salata and Shane J. Nho Am J Sports Med published online May 12, 2015 DOI: 10.1177/0363546515584042 The online version of this article can be found at: http://ajs.sagepub.com/content/early/2015/05/12/0363546515584042
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Evaluation of Sexual Function Before and After Hip Arthroscopic Surgery for Symptomatic Femoroacetabular Impingement Simon Lee,*y MD, MPH, Rachel M. Frank,y MD, Joshua Harris,z MD, Sang Hoon Song,y BS, Charles A. Bush-Joseph,y MD, Michael J. Salata,§ MD, and Shane J. Nho,y MD, MS Investigation performed at Rush University Medical Center, Chicago, Illinois, USA Background: It is unknown if chronic hip pain due to femoroacetabular impingement (FAI) may cause sexual difficulties. Available evidence suggests that hip arthroscopic surgery may be effective for the treatment of symptomatic FAI; however, sexual function before and after hip arthroscopic surgery has not been reported. Purpose/Hypothesis: The purpose of this study was to determine the presence and significance of sexual difficulties in patients with chronic hip pain due to symptomatic FAI both before and after hip arthroscopic surgery. The hypotheses were that (1) chronic hip pain due to symptomatic FAI has a negative effect on sexual function, (2) hip arthroscopic surgery improves the level of sexual function postoperatively, (3) the characteristics of sexual difficulties may be dependent on sex or age, (4) patients lack knowledge of potential sexual activity changes in the preoperative and postoperative periods, and (5) patients desire a greater level of discussion regarding potential changes in sexual function. Study Design: Case series; Level of evidence, 4. Methods: A 23-item Likert-style questionnaire assessing preoperative and postoperative sexual function and a modified Harris Hip Score questionnaire were administered to 305 consecutive patients who underwent hip arthroscopic surgery for FAI with a minimum 1-year follow-up. Comparative analysis was performed between sexes and age groups (young: \40 years; old: .40 years). Results: Of 131 respondents, preoperative sexual difficulties were reported by 66%, occurring 30.8 6 49.1 days after the onset of FAI symptoms. Primary causes of difficulty included pain (77.9%), stiffness (47.1%), and loss of interest (21.4%). Sexual activity resumed 29.2 6 20.1 days postoperatively, while sex with minimal pain occurred at 48.8 6 40.6 days. Female patients and older patients (.40 years old) resumed sexual activity later (female: 34.8 6 23.2 days; male: 21.0 6 10.7 days; P \ .0001) (young: 26.3 6 21.7 days; old: 35.7 6 13.5 days; P = .017). The frequency of sexual activity increased in 32.3%, decreased in 16.9%, and was unchanged in 48.5%. Among patients who reported an increase in the frequency of sexual activity, there was a greater proportion of male patients and younger patients (female: 38.1%; male: 61.9%; P \ .0001) (young: 78.6%; old: 21.4%; P \ .0001). More female patients reported alterations in sexual positioning (female: 82.3%; male: 17.7%; P \ .0001). To obtain information on sexual function, 77.4% of patients preferred a discussion with the surgeon, and 67.4% preferred a booklet on the subject. Relief of pain after arthroscopic surgery was experienced by 88.9%, and only 10.8% reported current sexual difficulties. Conclusion: This study demonstrates the prevalence of sexual difficulties among the majority of patients with symptomatic FAI, the significant effect that these difficulties may have on quality of life, and the ability of hip arthroscopic surgery to improve sexual function postoperatively. While further studies are required to elucidate what specific factors are associated with sexual difficulties, the current study suggests that this is an important topic to explore. Keywords: hip; femoroacetabular impingement; hip arthroscopic surgery; sexual function
including sexual functioning.7,32 Ganz et al14 have elucidated the complex morphological characteristics of the hip joint and characterized various biomechanical pathways in which abnormal anatomy of the region may produce symptomatic pathological changes. Femoroacetabular impingement (FAI) is perhaps a common cause of symptoms that may lead to chronic hip pain and lead patients to seek medical attention. As the symptomatic FAI population consists
Chronic hip pain has been shown to significantly affect patient quality of life and potentially alter the ability of patients to perform activities of daily living and recreation,
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primarily of younger adults, the importance of sexual activity is emphasized, and the difficulties that they experience may produce a significantly negative stress on their lives.6 There are several studies in the literature exploring sexual function in relation to pelvic and hip pathological disorders including total joint replacement, periacetabular osteotomy, pelvic fractures, and other orthopaedic disorders.k Stern et al28 found that in 86 patients with total hip arthroplasty (THA), 46% attributed significant preoperative sexual difficulties to their hip disorder, while only 1% felt that their hips continued to be a significant source of sexual problems postoperatively. Klit et al17 demonstrated that chronic hip pain also caused sexual dysfunction in a middle-aged population, examining 52 young patients (mean age, 41 years; range, 24-67 years) undergoing periacetabular osteotomy for symptomatic acetabular dysplasia of the hip. This study found that preoperative sexual difficulties were significantly improved 9 to 12 years postoperatively for female patients.17 Similarly, patients with FAI are often young and have high functional demands of their hip. Hip arthroscopic surgery may be an effective treatment for symptomatic FAI; however, any effect on sexual activity preoperatively and postoperatively has not been previously reported in the orthopaedic literature. Because of the lack of attention in the current literature on this overlooked, yet potentially important, topic within the symptomatic FAI population, the purpose of this study was to determine the presence and significance of sexual difficulties in patients with chronic hip pain due to symptomatic FAI both before and after hip arthroscopic surgery. The hypotheses were that (1) chronic hip pain due to symptomatic FAI has a negative effect on sexual function, (2) hip arthroscopic surgery improves the level of sexual function postoperatively, (3) the characteristics of sexual difficulties may be dependent on sex or age, (4) patients lack knowledge of potential sexual activity changes in the preoperative and postoperative periods, and (5) patients desire a greater level of discussion regarding potential changes in sexual function.
METHODS An institutional review board–approved retrospective study was performed. A consecutive cohort of 305 patients who underwent hip arthroscopic surgery for FAI by a single fellowship-trained surgeon from January 2011 to January 2013 were collected and analyzed. Inclusion criteria included patients between 18 and 65 years of age at the time of this study with physical examination and radiok
References 5, 7, 17, 18, 21, 22, 27, 28, 30, 31.
graphic findings consistent with symptomatic FAI who failed nonoperative management (consisting of physical therapy and/or intra-articular corticosteroid injections). All included patients underwent unilateral hip arthroscopic surgery with a diagnostic arthroscopic examination, labral repair or debridement, and capsular repair. Patients also underwent femoral osteochondroplasty for an isolated cam deformity, acetabular rim trimming for an isolated pincer deformity, or both for combined FAI. A minimum of 1-year follow-up was required. Exclusion criteria included patients with bilateral symptomatic hip disease, significant ipsilateral knee injury, history of ipsilateral hip or knee surgery, significant lumbosacral spine pathological abnormality, and workers’ compensation insurance. Patients with major medical comorbidities that may affect sexual function including congestive heart failure, coronary artery disease, previous myocardial infarction, peripheral vascular disease, diabetes, obesity, alcoholism, and depression were also excluded. Patients with previously established sexual difficulties or erectile dysfunction independent of their hip disorder were self-identified on the study questionnaire and excluded from the final analysis. A diagram depicting the flow of patient selection and inclusion is presented in Figure 1. An anonymous 23-item Likert-style questionnaire assessing preoperative and postoperative sexual function was mailed out to each patient’s home address (see the Appendix, available online at http://ajsm.sagepub.com/supplemental). An accompanying letter explaining the purpose of the study and a prepaid return envelope were also included. Also included was the modified Harris Hip Score (mHHS), a validated, hip patient-reported outcome measure with 8 items and 91 as the best score.2 The questionnaire modified items utilized in the studies of Currey,7 Meyer et al,21 and Laffosse et al18 and was adapted according to the Likert-style scale. These questions have been previously used to evaluate psychometric properties of patients undergoing THA for chronic hip pain, making them applicable to the chronic hip pain of a symptomatic FAI population. Each item provided boxes to select from 5 possible responses: strongly agree, agree, neither agree nor disagree, disagree, and strongly disagree. Comparative analysis was performed between sexes and age groups (young: \40 years; old: 40 years). After grouping, continuous variables were compared using an independent-samples t test, and nominal variables were compared with a x2 or Fisher exact test. Age, sex, and follow-up time were evaluated between each group, utilizing independent-samples t tests to determine any significant confounding effects. Analysis of the relationship between sexual dysfunction and the mHHS was also performed utilizing Pearson correlations and 1-way analysis of variance (ANOVA) with Games-Howell post hoc tests. Statistical analysis was conducted using SPSS software
*Address correspondence to Simon Lee, MD, MPH, Rush University Medical Center, 1611 West Harrison Street, Chicago, IL 60612, USA (email: [email protected]). y Rush University Medical Center, Chicago, Illinois, USA. z Houston Methodist Hospital, Houston, Texas, USA. § Case University Medical Center, Cleveland, Ohio, USA. The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.
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TABLE 1 Demographic Characteristics of Respondents as Compared With the Entire Cohort Respondents Entire Cohort (n = 131) (N = 305) P Value Age, mean 6 SD, y 35.2 6 11.6 Sex, n Male 56 Female 75 Side, n Right 73 Left 58 Follow-up, mean 6 SD, mo 21.0 6 5.4
Figure 1. Flow diagram depicting patient identification and selection. Inclusion and exclusion criteria are described at each level of patient selection. FAI, femoroacetabular impingement. (v 21.0; IBM Corp). All reported P values are 2-tailed, with an a level of .05 detecting significant differences.
RESULTS A total of 131 patients (75 female and 56 male; 92 young and 39 old) returned the study questionnaire for a response rate of 43.0%. The demographic characteristics of these patients were compared with the demographics of the entire cohort that received the questionnaire and were shown to be representative of the study population, with no significant differences in any demographic factor (Table 1). No significant differences in age (female: 34.5 6 10.9 years; male: 36.0 6 12.5 years; P = .462) or follow-up time (female: 20.7 6 5.31 months; male: 21.4 6 5.48 months; P = .457) were found between sexes. No significant differences in sex (P = .848) or follow-up time (young: 21.0 6 5.67 months; old: 21.0 6 4.66 months; P = .987) were found between age groups either. The majority of patients (66%) strongly agreed or agreed that they experienced preoperative sexual difficulties before hip arthroscopic surgery. The onset of sexual difficulties was variable among patients but occurred at a mean of 30.8 6 49.1 days after the onset of FAI symptoms with no differences detected between sexes or age status. The most commonly reported contributing factor to
32.7 6 13.1
.3871 .8324
126 179 .0945 142 163
Figure 2. Time (days) to resumption of sexual activity of respondents, stratified by sex and age group. alterations in sexual function was hip pain (77.9%), followed by stiffness (47.1%) and loss of interest (21.4%). No significant differences between sexes were found within these causes, but pain as a reason for sexual difficulty was shown to be significantly more likely in younger patients (82.9%) as compared with older patients (67.6%) (P = .016). Resumption of sexual activity occurred at a mean of 29.2 6 20.1 days after hip arthroscopic surgery, while sexual activity with minimal pain occurred at a mean of 48.8 6 40.6 days. Female patients resumed sexual activity significantly later than male patients (female: 34.8 6 23.2 days; male: 21.0 6 10.7 days; P \ .0001). In addition, older patients resumed sexual activity significantly later compared with younger patients (young: 26.3 6 21.7 days; old: 35.7 6 13.5 days; P = .017) (Figure 2). Postoperatively, only 10.8% strongly agreed or agreed that they experience current sexual difficulties. Additionally, 74.8% of patients strongly agreed or agreed that their sexual activity is currently enjoyable; 13.7% of patients reported unhappiness in their relationships because of sexual difficulties stemming from their hip pain, without any significant differences between sexes or age groups. In relation to changes in the frequency of sexual activity, 32.3% of patients reported an increase, while 16.9% of patients reported a decrease. The frequency of sexual activity was unchanged in 48.5% of patients and had not
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TABLE 2 Preferences for the Sources of Information About Sexual Function for the Patient and Partner Respondents, % Strongly Agree Information for the patient: patient preference Surgeon 43.9 Family doctor 2.7 Social worker 1.8 Nurse 4.1 Booklet 21.7 Information for the partner: patient preference for partner To be present during the conversation 19.0 To have a separate interview 0.9 To have a booklet 6.8
been resumed in 3 patients (2.3%). Among patients who reported an increase in the frequency of sexual activity, there was a significantly greater proportion of male patients as compared with female patients (female: 38.1%; male: 61.9%; P \ .0001). Additionally, there was a significantly greater proportion of young patients as compared with older patients among those who reported an increased frequency of sexual activity (young: 78.6%; old: 21.4%; P \ .0001). There were no statistically significant differences between sexes or age groups among patients who reported a decrease in the frequency of sexual activity. When analyzing whether patients required a change in their normal sexual positions, 29.0% strongly agreed or agreed that their hip pain caused them to adjust their positioning. Among the patients who required a change in position, a significantly greater proportion were female patients as compared with male patients (female: 82.3%; male: 17.7%; P \ .0001). There were no significant differences between age groups with regard to sexual positioning. Only 28.1% of respondents reported receiving information concerning sexual activity before and/or after hip arthroscopic surgery. In order of preference, patients desired a discussion with the surgeon (77.4%), a booklet or handout about the subject (67.4%), a discussion with a family physician (36.6%), a discussion with a nurse (17.2%), and lastly, a discussion with a medical social worker (6.3%). Female patients were significantly more likely to want their partners to be present during the discussion with the surgeon (P = .02) and for their partners to receive a booklet (P = .01) (Table 2). The majority of patients experienced successful clinical outcomes after surgery, with 88.9% of patients strongly agreeing or agreeing that they experienced pain relief after hip arthroscopic surgery. Patients also reported a mean satisfaction score of 8.8 of 10 on a numerical scale from 0 (not satisfied at all) to 10 (very satisfied). The mean mHHS at final follow-up was 84.6 6 6.7. There were no mHHS statistical differences between sexes, but scores for younger patients were significantly greater than for older patients (young: 87.6 6 6.7; old: 82.1 6 8.3; P = .0148) (Figure 3). The mHHS was negatively correlated with time to resumption of sexual activity (R = –0.271;
Agree
Neither
Disagree
Strongly Disagree
33.5 33.9 4.5 13.1 45.7
18.1 32.6 29.4 20.4 25.8
4.1 20.8 25.8 23.5 4.1
0.5 10.0 38.5 38.9 2.7
26.7 2.3 20.8
32.6 16.3 19.9
13.1 29.9 23.1
8.6 50.7 29.4
Figure 3. Modified Harris Hip Score (mHHS) stratified by sex and age group. P = .002), negatively correlated with time to sexual activity with minimal pain (R = –0.305; P = .001), and positively correlated with patient satisfaction (R = 0.666; P \ .0001). Additionally, patients experiencing differences in postoperative sexual frequency demonstrated significantly different mHHS values (increased: 86.1; no change: 82.9; decreased: 75.5; ANOVA: P \ .0001). Interestingly, 28 respondents (21.4%) also included an unsolicited comment about their interest in the purpose and results of the study on the returned surveys.
DISCUSSION The principal findings of this study are that (1) a majority of patients reported experiencing sexual difficulties associated with hip pain due to symptomatic FAI, (2) hip arthroscopic surgery for symptomatic FAI is associated with an improvement in these difficulties, (3) female and older patients reported worse sexual difficulties as compared with male or younger patients, (4) discussion about sexual difficulties in the preoperative and postoperative period was infrequent, and (5) patients desired and may benefit from additional discussion or information specific to this issue.
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While much of the current literature focuses on sexual function in relation to chronic hip pain stemming from osteoarthritis and total joint arthroplasty, many of these findings are applicable to the younger symptomatic FAI population.5,7,8,18,21,28,30-32 Sexual difficulty due to hip pain is a present and significant issue as studies have shown that alterations in function may occur in more than 50% of patients suffering from chronic hip pain.7,32 In addition to pain, fear of exacerbating pain, fatigue, and stiffness, as well as potential side effects of pain medications, may also affect sexual function.1,28 It can also be postulated that sexual function may be of greater importance to the younger symptomatic FAI population because of the increased frequency of activity.15 The arthroscopic management of FAI to address morphological abnormalities and their subsequent pathological sequelae is becoming a common and safe method of treating hip pain.4,9-12,19,23-26 Laffosse et al18 performed a similar study evaluating sexual function after THA and demonstrated that female patients resumed activity significantly later than male patients (P = .0005). The current study demonstrates that the hip arthroscopic surgery population returned to sexual activity much earlier postoperatively, potentially attributed to a comparatively less invasive procedure, the population group’s younger age, and possibly, a higher desire to return to sexual activity. However, this study mirrors the Laffosse et al18 finding that female patients return to sexual activity later as compared with male patients (P \ .0001). Additionally, a significantly greater proportion of patients who reported an increase in sexual activity after hip arthroscopic surgery were men (P \ .0001). Interestingly, 16.9% of patients reported a decrease in sexual frequency postoperatively. While this study cannot determine if this decrease in frequency was directly in response to hip arthroscopic surgery, it is important to consider the possibility that surgical intervention and postoperative recovery may introduce novel challenges to sexual function that may not have been present preoperatively. These issues include but are not limited to postoperative pain and sexual difficulties associated with the use of chronic opioid pain medication. However, many other potential causes of decreased sexual activity independent of surgical care may exist including individual psychosocial issues. While the scope of this study cannot answer these questions, it is an important topic for further exploration. These findings, in conjunction with the observation that female patients reported a higher rate of altering their sexual positioning (P \ .0001), indicate that female patients may be experiencing sex-specific difficulties in returning to sexual activity as compared with male patients. Laffosse et al18 reported that while male patients did not demonstrate a significant change in sexual positioning, female patients tended to change their positions to those requiring less mobility, avoiding abduction and external rotation. These results were confirmed by an in vivo motion capture study by Charbonnier et al,5 demonstrating that sexual positions for women require extreme hip range of motion (high flexion combined with abduction and mostly external rotation), whereas sexual positions for men require less
mobility (but with pronounced external rotation). While these studies are examining sexual positioning in relation to THA, they provide evidence that sexual positions for female patients in general require a higher degree of hip articulation, which may exacerbate pain and discomfort of other hip pathological entities such as FAI. Whether hip arthroscopic surgery had any effect on restoring the ability for these patients to achieve their normal sexual positioning was beyond the scope of this study; however, further studies dedicated to this question would be valuable as positioning is an important topic in relation to sexual function. This study also observed age-related differences in sexual activity. After grouping respondents into patients \40 years old and those .40 years old, we found that older patients resume sexual activity significantly later as compared with younger patients (P = .017). A greater proportion of younger patients also reported pain as a primary reason for sexual difficulties as compared with older patients (P \ .0001). Also, a significantly higher proportion of younger patients reported increased sexual activity postoperatively as compared with older patients (P \ .0001). The 3 patients who reported no return to sexual activity were women and older than 50 years (51, 54, and 57 years). Although this subset of patients is too small to statistically compare with the remaining respondents, this finding is noteworthy when considered with the relatively worse sexual function outcomes demonstrated by both the female and older patient groups. Age-related vascular, neurogenic, hormonal, endocrine, muscular, and psychogenic sexual issues related to female physiology may present unique barriers for the recovery of sexual health after surgical intervention such as hip arthroscopic surgery.3 This trend is reflected in studies evaluating sexual function after hip arthroplasty, with female patients demonstrating significantly greater postoperative sexual difficulties, greater time to sexual activity resumption, and lower rates of return to sexual activity.7,18,28 The likelihood of patients over 40 years old having more severe degenerative changes is increased, potentially leading to worse functional outcomes, including sexual activity. While Philippon et al25 have reported good clinical outcomes in a cohort of 153 patients aged 50 years with hip arthroscopic surgery, these results were still inferior to those of younger cohorts. This study demonstrates that older age in relation to hip arthroscopic surgery may contribute to a generally more difficult recovery, especially in the presence of osteoarthritis. The current study reflects these findings, demonstrating that mHHS values for younger patients were significantly greater than for older patients (P = .0148). The persistent, chronic hip pain that this population experiences may lead to additional complications, including a delay in return to sexual activity. Taken together, this information suggests that while patients undergoing hip arthroscopic surgery for FAI generally perform well postoperatively, it may be prudent to advise female and older patients that their recovery for sexual activity may be longer and less complete as compared with male and younger patients. While the current study demonstrates that sexual difficulties are prevalent among patients undergoing hip
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arthroscopic surgery, a relatively small proportion of these patients reported receiving any advice on this issue (28.1%). These patients independently raised the topic, as sexual function is not routinely discussed in the preoperative or postoperative period. Additionally, a reasonably high number of patients provided unsolicited comments in relation to the subject, potentially demonstrating sexual difficulties in relation to hip arthroscopic surgery and FAI may be underestimated by clinicians. These comments also suggest that patients may tend to not freely discuss these issues with the physician unless prompted. Dahm et al8 underlined the lack of importance given to the subject by 80% of practitioners who rarely, if ever, discussed sexual activity after THA with their patients. In addition, of surgeons who stated that they did discuss this topic, 96% spent 5 minutes or less.8 In a retrospective study, Wall et al30 found that only 36% of surgeons inquired preoperatively if symptoms were interfering with patients’ sex lives, and only 39% provided written information about sexual activity after THA. Only 25% of surgeons regularly advised patients about an appropriate time to resume sexual activity.30 In the current study’s cohort, a majority of patients noted that they would respond positively to a discussion with their surgeon (77.4%) or to receiving a booklet or handout about the subject (67.4%). Sexual function is a sensitive topic to discuss, but this study suggests that it is an important issue for patients with symptomatic FAI undergoing hip arthroscopic surgery and that physicians’ advice on appropriate expectations would be beneficial. There has been a significant trend toward utilizing patient-reported outcome scores in the evaluation of a patient’s quality of life and functional outcomes with hip arthroscopic surgery. However, the patient-reported outcome surveys commonly utilized by hip arthroscopic surgeons rarely take into account sexual functionality. Questionnaires such as the Copenhagen Hip and Groin Outcome Score, Hip Outcome Score, mHHS, Nonarthritic Hip Score, and International Hip Outcome Tool (iHOT-33) thoroughly analyze activities of daily living and sport-specific activities, but only the iHOT-33 contains a single question in relation to sexual difficulties.16,20,29 Also, even while this question exists, functional outcome surveys are typically analyzed as an aggregate, only utilizing the final score for clinical purposes and decision making. The current study found that mHHS values were negatively correlated with time to resumption of sexual activity (P = .002) and negatively correlated with time to sexual activity with minimal pain (P = .001). Additionally, patients reporting increased sexual frequency demonstrated higher mHHS values as compared with patients reporting decreased sexual frequency (P \ .0001). However, no significant correlations or relationships were found among the mHHS and other critical questions about sexual function such as continued postoperative sexual difficulties, whether sexual activity had been enjoyable, and whether the patient required changes in sexual positioning. While these findings show that the mHHS may be able to imply some aspects of postoperative sexual activity, they also support the notion that sexual activity may be a unique functional aspect that is not sensitively evaluated by outcome scores. While
sexual function may be indirectly related to other questions on these surveys, it is a unique issue that may be better evaluated separately to better detect its presence and to provide more appropriate management.
Limitations This study has several limitations including its retrospective nature utilizing an anonymous questionnaire sent by physical mail, significantly limiting its effect. A prospective study directly interviewing each patient would entail less methodological bias; however, this design also introduces unique problems as well. The current study is a retrospective, level 4 case series study, a study type that is susceptible to overinflating effects and differences being reported.13 However, the advantage of the current study’s methodology includes anonymity, allowing patients to more freely and honestly answer questions on this sensitive topic. Conversely, this process only allows for 1-way communication from the study staff toward the patient, omitting any potential clarification of questions. The retrospective nature of this study also limits the conclusions that could be made from the collected data. Significant recall bias exists as the accuracy of patient recollection cannot be guaranteed. Self-selection bias may also exist as it was under the patients’ own prerogative to complete and return the questionnaire. It is possible that patients demonstrating sexual difficulties were more likely to respond to the questionnaire, resulting in overreporting of sexual difficulties in this study. The current study achieved a response rate of 43% as compared with similar studies in the literature that reported response rates ranging from 33% to 86%. While the current study’s response rate may appear below average, the population in question must be accounted for and put into perspective. The mHHS utilized in this study has a large ceiling effect and limited psychometric properties as well as content validity for this patient population. This patientreported outcome score was selected for its brevity as it had the least amount of questions as compared with other commonly utilized questionnaires for the hip, while still containing sufficient content to analyze general functional outcomes for this study population. Additionally, this study did not reference ‘‘normal’’ sexual function in this age group as a control group was not available. Finally, this study had a minimum follow-up of 1 year, which may be too short a duration to adequately assess clinical outcomes. However, based on prior similar studies assessing different surgical procedures, the vast majority of patients resume sexual activity well within 1 year after surgery, and often within several months, and thus, we felt a 1-year time period was appropriate for the purposes of assessing sexual activity in this study.
CONCLUSION This study demonstrates the prevalence of sexual difficulties among the majority of patients with symptomatic FAI, the significant effect that these difficulties may have on quality
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of life, and the ability for hip arthroscopic surgery to improve sexual function postoperatively. While further studies are required to elucidate what specific factors are associated with sexual difficulties, the current study suggests that this is an important topic to explore.
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16. Kemp JL, Collins NJ, Roos EM, Crossley KM. Psychometric properties of patient-reported outcome measures for hip arthroscopic surgery. Am J Sports Med. 2013;41(9):2065-2073. 17. Klit J, Hartig-Andreasen C, Jacobsen S, Søballe K, Troelsen A. Periacetabular osteotomy: sporting, social and sexual activity 9-12 years post surgery. Hip Int. 2014;24(1):27-31. 18. Laffosse J-M, Tricoire J-L, Chiron P, Puget J. Sexual function before and after primary total hip arthroplasty. Joint Bone Spine. 2008;75(2):189-194. 19. Larson CM, Giveans MR, Stone RM. Arthroscopic debridement versus refixation of the acetabular labrum associated with femoroacetabular impingement: mean 3.5-year follow-up. Am J Sports Med. 2012;40(5):1015-1021. 20. Martin RL, Philippon MJ. Evidence of reliability and responsiveness for the hip outcome score. Arthroscopy. 2008;24(6):676-682. 21. Meyer H, Stern R, Fusetti C, Salsano F, Campana A, Hoffmeyer P. Sexual quality-of-life after hip surgery. J Orthop Traumatol. 2003;4(1):21-25. 22. Odutola AA, Sabri O, Halliday R, Chesser TJS, Ward AJ. High rates of sexual and urinary dysfunction after surgically treated displaced pelvic ring injuries. Clin Orthop Relat Res. 2012;470(8):2173-2184. 23. O’leary JA, Berend K, Vail TP. The relationship between diagnosis and outcome in arthroscopy of the hip. Arthroscopy. 2001;17(2): 181-188. 24. Philippon MJ, Ejnisman L, Ellis HB, Briggs KK. Outcomes 2 to 5 years following hip arthroscopy for femoroacetabular impingement in the patient aged 11 to 16 years. Arthroscopy. 2012;28(9):1255-1261. 25. Philippon MJ, Schroder e Souza BG, Briggs KK. Hip arthroscopy for femoroacetabular impingement in patients aged 50 years or older. Arthroscopy. 2012;28(1):59-65. 26. Philippon MJ, Yen Y-M, Briggs KK, Kuppersmith DA, Maxwell RB. Early outcomes after hip arthroscopy for femoroacetabular impingement in the athletic adolescent patient: a preliminary report. J Pediatr Orthop. 2008;28(7):705-710. 27. Sariyildiz MA, Batmaz I, Dilek B, et al. Relationship of the sexual functions with the clinical parameters, radiological scores and the quality of life in male patients with ankylosing spondylitis. Rheumatol Int. 2013;33(3):623-629. 28. Stern SH, Fuchs MD, Ganz SB, Classi P, Sculco TP, Salvati EA. Sexual function after total hip arthroplasty. Clin Orthop Relat Res. 1991;269:228-235. 29. Tijssen M, van Cingel R, van Melick N, de Visser E. Patient-reported outcome questionnaires for hip arthroscopy: a systematic review of the psychometric evidence. BMC Musculoskelet Disord. 2011;12:117. 30. Wall PDH, Hossain M, Ganapathi M, Andrew JG. Sexual activity and total hip arthroplasty: a survey of patients’ and surgeons’ perspectives. Hip Int. 2011;21(2):199-205. 31. Wang B-L, Yue D-B, Liu BX, Guo W-S. Quality of sexual life after total hip arthroplasty in male patients with osteonecrosis of femoral head. Eur J Orthop Surg Traumatol. 2014;24(7):1217-1221. 32. Wiklund I, Romanus B. A comparison of quality of life before and after arthroplasty in patients who had arthrosis of the hip joint. J Bone Joint Surg Am. 1991;73(5):765-769.
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Evaluation of Sexual Function Before and After Hip Arthroscopic Surgery for Symptomatic Femoroacetabular Impingement Simon Lee, Rachel M. Frank, Joshua Harris, Sang Hoon Song, Charles A. Bush-Joseph, Michael J. Salata and Shane J. Nho Am J Sports Med published online May 12, 2015 DOI: 10.1177/0363546515584042 The online version of this article can be found at: http://ajs.sagepub.com/content/early/2015/05/12/0363546515584042
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Evaluation of Sexual Function Before and After Hip Arthroscopic Surgery for Symptomatic Femoroacetabular Impingement Simon Lee,*y MD, MPH, Rachel M. Frank,y MD, Joshua Harris,z MD, Sang Hoon Song,y BS, Charles A. Bush-Joseph,y MD, Michael J. Salata,§ MD, and Shane J. Nho,y MD, MS Investigation performed at Rush University Medical Center, Chicago, Illinois, USA Background: It is unknown if chronic hip pain due to femoroacetabular impingement (FAI) may cause sexual difficulties. Available evidence suggests that hip arthroscopic surgery may be effective for the treatment of symptomatic FAI; however, sexual function before and after hip arthroscopic surgery has not been reported. Purpose/Hypothesis: The purpose of this study was to determine the presence and significance of sexual difficulties in patients with chronic hip pain due to symptomatic FAI both before and after hip arthroscopic surgery. The hypotheses were that (1) chronic hip pain due to symptomatic FAI has a negative effect on sexual function, (2) hip arthroscopic surgery improves the level of sexual function postoperatively, (3) the characteristics of sexual difficulties may be dependent on sex or age, (4) patients lack knowledge of potential sexual activity changes in the preoperative and postoperative periods, and (5) patients desire a greater level of discussion regarding potential changes in sexual function. Study Design: Case series; Level of evidence, 4. Methods: A 23-item Likert-style questionnaire assessing preoperative and postoperative sexual function and a modified Harris Hip Score questionnaire were administered to 305 consecutive patients who underwent hip arthroscopic surgery for FAI with a minimum 1-year follow-up. Comparative analysis was performed between sexes and age groups (young: \40 years; old: .40 years). Results: Of 131 respondents, preoperative sexual difficulties were reported by 66%, occurring 30.8 6 49.1 days after the onset of FAI symptoms. Primary causes of difficulty included pain (77.9%), stiffness (47.1%), and loss of interest (21.4%). Sexual activity resumed 29.2 6 20.1 days postoperatively, while sex with minimal pain occurred at 48.8 6 40.6 days. Female patients and older patients (.40 years old) resumed sexual activity later (female: 34.8 6 23.2 days; male: 21.0 6 10.7 days; P \ .0001) (young: 26.3 6 21.7 days; old: 35.7 6 13.5 days; P = .017). The frequency of sexual activity increased in 32.3%, decreased in 16.9%, and was unchanged in 48.5%. Among patients who reported an increase in the frequency of sexual activity, there was a greater proportion of male patients and younger patients (female: 38.1%; male: 61.9%; P \ .0001) (young: 78.6%; old: 21.4%; P \ .0001). More female patients reported alterations in sexual positioning (female: 82.3%; male: 17.7%; P \ .0001). To obtain information on sexual function, 77.4% of patients preferred a discussion with the surgeon, and 67.4% preferred a booklet on the subject. Relief of pain after arthroscopic surgery was experienced by 88.9%, and only 10.8% reported current sexual difficulties. Conclusion: This study demonstrates the prevalence of sexual difficulties among the majority of patients with symptomatic FAI, the significant effect that these difficulties may have on quality of life, and the ability of hip arthroscopic surgery to improve sexual function postoperatively. While further studies are required to elucidate what specific factors are associated with sexual difficulties, the current study suggests that this is an important topic to explore. Keywords: hip; femoroacetabular impingement; hip arthroscopic surgery; sexual function
including sexual functioning.7,32 Ganz et al14 have elucidated the complex morphological characteristics of the hip joint and characterized various biomechanical pathways in which abnormal anatomy of the region may produce symptomatic pathological changes. Femoroacetabular impingement (FAI) is perhaps a common cause of symptoms that may lead to chronic hip pain and lead patients to seek medical attention. As the symptomatic FAI population consists
Chronic hip pain has been shown to significantly affect patient quality of life and potentially alter the ability of patients to perform activities of daily living and recreation,
The American Journal of Sports Medicine, Vol. XX, No. X DOI: 10.1177/0363546515584042 Ó 2015 The Author(s)
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primarily of younger adults, the importance of sexual activity is emphasized, and the difficulties that they experience may produce a significantly negative stress on their lives.6 There are several studies in the literature exploring sexual function in relation to pelvic and hip pathological disorders including total joint replacement, periacetabular osteotomy, pelvic fractures, and other orthopaedic disorders.k Stern et al28 found that in 86 patients with total hip arthroplasty (THA), 46% attributed significant preoperative sexual difficulties to their hip disorder, while only 1% felt that their hips continued to be a significant source of sexual problems postoperatively. Klit et al17 demonstrated that chronic hip pain also caused sexual dysfunction in a middle-aged population, examining 52 young patients (mean age, 41 years; range, 24-67 years) undergoing periacetabular osteotomy for symptomatic acetabular dysplasia of the hip. This study found that preoperative sexual difficulties were significantly improved 9 to 12 years postoperatively for female patients.17 Similarly, patients with FAI are often young and have high functional demands of their hip. Hip arthroscopic surgery may be an effective treatment for symptomatic FAI; however, any effect on sexual activity preoperatively and postoperatively has not been previously reported in the orthopaedic literature. Because of the lack of attention in the current literature on this overlooked, yet potentially important, topic within the symptomatic FAI population, the purpose of this study was to determine the presence and significance of sexual difficulties in patients with chronic hip pain due to symptomatic FAI both before and after hip arthroscopic surgery. The hypotheses were that (1) chronic hip pain due to symptomatic FAI has a negative effect on sexual function, (2) hip arthroscopic surgery improves the level of sexual function postoperatively, (3) the characteristics of sexual difficulties may be dependent on sex or age, (4) patients lack knowledge of potential sexual activity changes in the preoperative and postoperative periods, and (5) patients desire a greater level of discussion regarding potential changes in sexual function.
METHODS An institutional review board–approved retrospective study was performed. A consecutive cohort of 305 patients who underwent hip arthroscopic surgery for FAI by a single fellowship-trained surgeon from January 2011 to January 2013 were collected and analyzed. Inclusion criteria included patients between 18 and 65 years of age at the time of this study with physical examination and radiok
References 5, 7, 17, 18, 21, 22, 27, 28, 30, 31.
graphic findings consistent with symptomatic FAI who failed nonoperative management (consisting of physical therapy and/or intra-articular corticosteroid injections). All included patients underwent unilateral hip arthroscopic surgery with a diagnostic arthroscopic examination, labral repair or debridement, and capsular repair. Patients also underwent femoral osteochondroplasty for an isolated cam deformity, acetabular rim trimming for an isolated pincer deformity, or both for combined FAI. A minimum of 1-year follow-up was required. Exclusion criteria included patients with bilateral symptomatic hip disease, significant ipsilateral knee injury, history of ipsilateral hip or knee surgery, significant lumbosacral spine pathological abnormality, and workers’ compensation insurance. Patients with major medical comorbidities that may affect sexual function including congestive heart failure, coronary artery disease, previous myocardial infarction, peripheral vascular disease, diabetes, obesity, alcoholism, and depression were also excluded. Patients with previously established sexual difficulties or erectile dysfunction independent of their hip disorder were self-identified on the study questionnaire and excluded from the final analysis. A diagram depicting the flow of patient selection and inclusion is presented in Figure 1. An anonymous 23-item Likert-style questionnaire assessing preoperative and postoperative sexual function was mailed out to each patient’s home address (see the Appendix, available online at http://ajsm.sagepub.com/supplemental). An accompanying letter explaining the purpose of the study and a prepaid return envelope were also included. Also included was the modified Harris Hip Score (mHHS), a validated, hip patient-reported outcome measure with 8 items and 91 as the best score.2 The questionnaire modified items utilized in the studies of Currey,7 Meyer et al,21 and Laffosse et al18 and was adapted according to the Likert-style scale. These questions have been previously used to evaluate psychometric properties of patients undergoing THA for chronic hip pain, making them applicable to the chronic hip pain of a symptomatic FAI population. Each item provided boxes to select from 5 possible responses: strongly agree, agree, neither agree nor disagree, disagree, and strongly disagree. Comparative analysis was performed between sexes and age groups (young: \40 years; old: 40 years). After grouping, continuous variables were compared using an independent-samples t test, and nominal variables were compared with a x2 or Fisher exact test. Age, sex, and follow-up time were evaluated between each group, utilizing independent-samples t tests to determine any significant confounding effects. Analysis of the relationship between sexual dysfunction and the mHHS was also performed utilizing Pearson correlations and 1-way analysis of variance (ANOVA) with Games-Howell post hoc tests. Statistical analysis was conducted using SPSS software
*Address correspondence to Simon Lee, MD, MPH, Rush University Medical Center, 1611 West Harrison Street, Chicago, IL 60612, USA (email: [email protected]). y Rush University Medical Center, Chicago, Illinois, USA. z Houston Methodist Hospital, Houston, Texas, USA. § Case University Medical Center, Cleveland, Ohio, USA. The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.
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TABLE 1 Demographic Characteristics of Respondents as Compared With the Entire Cohort Respondents Entire Cohort (n = 131) (N = 305) P Value Age, mean 6 SD, y 35.2 6 11.6 Sex, n Male 56 Female 75 Side, n Right 73 Left 58 Follow-up, mean 6 SD, mo 21.0 6 5.4
Figure 1. Flow diagram depicting patient identification and selection. Inclusion and exclusion criteria are described at each level of patient selection. FAI, femoroacetabular impingement. (v 21.0; IBM Corp). All reported P values are 2-tailed, with an a level of .05 detecting significant differences.
RESULTS A total of 131 patients (75 female and 56 male; 92 young and 39 old) returned the study questionnaire for a response rate of 43.0%. The demographic characteristics of these patients were compared with the demographics of the entire cohort that received the questionnaire and were shown to be representative of the study population, with no significant differences in any demographic factor (Table 1). No significant differences in age (female: 34.5 6 10.9 years; male: 36.0 6 12.5 years; P = .462) or follow-up time (female: 20.7 6 5.31 months; male: 21.4 6 5.48 months; P = .457) were found between sexes. No significant differences in sex (P = .848) or follow-up time (young: 21.0 6 5.67 months; old: 21.0 6 4.66 months; P = .987) were found between age groups either. The majority of patients (66%) strongly agreed or agreed that they experienced preoperative sexual difficulties before hip arthroscopic surgery. The onset of sexual difficulties was variable among patients but occurred at a mean of 30.8 6 49.1 days after the onset of FAI symptoms with no differences detected between sexes or age status. The most commonly reported contributing factor to
32.7 6 13.1
.3871 .8324
126 179 .0945 142 163
Figure 2. Time (days) to resumption of sexual activity of respondents, stratified by sex and age group. alterations in sexual function was hip pain (77.9%), followed by stiffness (47.1%) and loss of interest (21.4%). No significant differences between sexes were found within these causes, but pain as a reason for sexual difficulty was shown to be significantly more likely in younger patients (82.9%) as compared with older patients (67.6%) (P = .016). Resumption of sexual activity occurred at a mean of 29.2 6 20.1 days after hip arthroscopic surgery, while sexual activity with minimal pain occurred at a mean of 48.8 6 40.6 days. Female patients resumed sexual activity significantly later than male patients (female: 34.8 6 23.2 days; male: 21.0 6 10.7 days; P \ .0001). In addition, older patients resumed sexual activity significantly later compared with younger patients (young: 26.3 6 21.7 days; old: 35.7 6 13.5 days; P = .017) (Figure 2). Postoperatively, only 10.8% strongly agreed or agreed that they experience current sexual difficulties. Additionally, 74.8% of patients strongly agreed or agreed that their sexual activity is currently enjoyable; 13.7% of patients reported unhappiness in their relationships because of sexual difficulties stemming from their hip pain, without any significant differences between sexes or age groups. In relation to changes in the frequency of sexual activity, 32.3% of patients reported an increase, while 16.9% of patients reported a decrease. The frequency of sexual activity was unchanged in 48.5% of patients and had not
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TABLE 2 Preferences for the Sources of Information About Sexual Function for the Patient and Partner Respondents, % Strongly Agree Information for the patient: patient preference Surgeon 43.9 Family doctor 2.7 Social worker 1.8 Nurse 4.1 Booklet 21.7 Information for the partner: patient preference for partner To be present during the conversation 19.0 To have a separate interview 0.9 To have a booklet 6.8
been resumed in 3 patients (2.3%). Among patients who reported an increase in the frequency of sexual activity, there was a significantly greater proportion of male patients as compared with female patients (female: 38.1%; male: 61.9%; P \ .0001). Additionally, there was a significantly greater proportion of young patients as compared with older patients among those who reported an increased frequency of sexual activity (young: 78.6%; old: 21.4%; P \ .0001). There were no statistically significant differences between sexes or age groups among patients who reported a decrease in the frequency of sexual activity. When analyzing whether patients required a change in their normal sexual positions, 29.0% strongly agreed or agreed that their hip pain caused them to adjust their positioning. Among the patients who required a change in position, a significantly greater proportion were female patients as compared with male patients (female: 82.3%; male: 17.7%; P \ .0001). There were no significant differences between age groups with regard to sexual positioning. Only 28.1% of respondents reported receiving information concerning sexual activity before and/or after hip arthroscopic surgery. In order of preference, patients desired a discussion with the surgeon (77.4%), a booklet or handout about the subject (67.4%), a discussion with a family physician (36.6%), a discussion with a nurse (17.2%), and lastly, a discussion with a medical social worker (6.3%). Female patients were significantly more likely to want their partners to be present during the discussion with the surgeon (P = .02) and for their partners to receive a booklet (P = .01) (Table 2). The majority of patients experienced successful clinical outcomes after surgery, with 88.9% of patients strongly agreeing or agreeing that they experienced pain relief after hip arthroscopic surgery. Patients also reported a mean satisfaction score of 8.8 of 10 on a numerical scale from 0 (not satisfied at all) to 10 (very satisfied). The mean mHHS at final follow-up was 84.6 6 6.7. There were no mHHS statistical differences between sexes, but scores for younger patients were significantly greater than for older patients (young: 87.6 6 6.7; old: 82.1 6 8.3; P = .0148) (Figure 3). The mHHS was negatively correlated with time to resumption of sexual activity (R = –0.271;
Agree
Neither
Disagree
Strongly Disagree
33.5 33.9 4.5 13.1 45.7
18.1 32.6 29.4 20.4 25.8
4.1 20.8 25.8 23.5 4.1
0.5 10.0 38.5 38.9 2.7
26.7 2.3 20.8
32.6 16.3 19.9
13.1 29.9 23.1
8.6 50.7 29.4
Figure 3. Modified Harris Hip Score (mHHS) stratified by sex and age group. P = .002), negatively correlated with time to sexual activity with minimal pain (R = –0.305; P = .001), and positively correlated with patient satisfaction (R = 0.666; P \ .0001). Additionally, patients experiencing differences in postoperative sexual frequency demonstrated significantly different mHHS values (increased: 86.1; no change: 82.9; decreased: 75.5; ANOVA: P \ .0001). Interestingly, 28 respondents (21.4%) also included an unsolicited comment about their interest in the purpose and results of the study on the returned surveys.
DISCUSSION The principal findings of this study are that (1) a majority of patients reported experiencing sexual difficulties associated with hip pain due to symptomatic FAI, (2) hip arthroscopic surgery for symptomatic FAI is associated with an improvement in these difficulties, (3) female and older patients reported worse sexual difficulties as compared with male or younger patients, (4) discussion about sexual difficulties in the preoperative and postoperative period was infrequent, and (5) patients desired and may benefit from additional discussion or information specific to this issue.
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While much of the current literature focuses on sexual function in relation to chronic hip pain stemming from osteoarthritis and total joint arthroplasty, many of these findings are applicable to the younger symptomatic FAI population.5,7,8,18,21,28,30-32 Sexual difficulty due to hip pain is a present and significant issue as studies have shown that alterations in function may occur in more than 50% of patients suffering from chronic hip pain.7,32 In addition to pain, fear of exacerbating pain, fatigue, and stiffness, as well as potential side effects of pain medications, may also affect sexual function.1,28 It can also be postulated that sexual function may be of greater importance to the younger symptomatic FAI population because of the increased frequency of activity.15 The arthroscopic management of FAI to address morphological abnormalities and their subsequent pathological sequelae is becoming a common and safe method of treating hip pain.4,9-12,19,23-26 Laffosse et al18 performed a similar study evaluating sexual function after THA and demonstrated that female patients resumed activity significantly later than male patients (P = .0005). The current study demonstrates that the hip arthroscopic surgery population returned to sexual activity much earlier postoperatively, potentially attributed to a comparatively less invasive procedure, the population group’s younger age, and possibly, a higher desire to return to sexual activity. However, this study mirrors the Laffosse et al18 finding that female patients return to sexual activity later as compared with male patients (P \ .0001). Additionally, a significantly greater proportion of patients who reported an increase in sexual activity after hip arthroscopic surgery were men (P \ .0001). Interestingly, 16.9% of patients reported a decrease in sexual frequency postoperatively. While this study cannot determine if this decrease in frequency was directly in response to hip arthroscopic surgery, it is important to consider the possibility that surgical intervention and postoperative recovery may introduce novel challenges to sexual function that may not have been present preoperatively. These issues include but are not limited to postoperative pain and sexual difficulties associated with the use of chronic opioid pain medication. However, many other potential causes of decreased sexual activity independent of surgical care may exist including individual psychosocial issues. While the scope of this study cannot answer these questions, it is an important topic for further exploration. These findings, in conjunction with the observation that female patients reported a higher rate of altering their sexual positioning (P \ .0001), indicate that female patients may be experiencing sex-specific difficulties in returning to sexual activity as compared with male patients. Laffosse et al18 reported that while male patients did not demonstrate a significant change in sexual positioning, female patients tended to change their positions to those requiring less mobility, avoiding abduction and external rotation. These results were confirmed by an in vivo motion capture study by Charbonnier et al,5 demonstrating that sexual positions for women require extreme hip range of motion (high flexion combined with abduction and mostly external rotation), whereas sexual positions for men require less
mobility (but with pronounced external rotation). While these studies are examining sexual positioning in relation to THA, they provide evidence that sexual positions for female patients in general require a higher degree of hip articulation, which may exacerbate pain and discomfort of other hip pathological entities such as FAI. Whether hip arthroscopic surgery had any effect on restoring the ability for these patients to achieve their normal sexual positioning was beyond the scope of this study; however, further studies dedicated to this question would be valuable as positioning is an important topic in relation to sexual function. This study also observed age-related differences in sexual activity. After grouping respondents into patients \40 years old and those .40 years old, we found that older patients resume sexual activity significantly later as compared with younger patients (P = .017). A greater proportion of younger patients also reported pain as a primary reason for sexual difficulties as compared with older patients (P \ .0001). Also, a significantly higher proportion of younger patients reported increased sexual activity postoperatively as compared with older patients (P \ .0001). The 3 patients who reported no return to sexual activity were women and older than 50 years (51, 54, and 57 years). Although this subset of patients is too small to statistically compare with the remaining respondents, this finding is noteworthy when considered with the relatively worse sexual function outcomes demonstrated by both the female and older patient groups. Age-related vascular, neurogenic, hormonal, endocrine, muscular, and psychogenic sexual issues related to female physiology may present unique barriers for the recovery of sexual health after surgical intervention such as hip arthroscopic surgery.3 This trend is reflected in studies evaluating sexual function after hip arthroplasty, with female patients demonstrating significantly greater postoperative sexual difficulties, greater time to sexual activity resumption, and lower rates of return to sexual activity.7,18,28 The likelihood of patients over 40 years old having more severe degenerative changes is increased, potentially leading to worse functional outcomes, including sexual activity. While Philippon et al25 have reported good clinical outcomes in a cohort of 153 patients aged 50 years with hip arthroscopic surgery, these results were still inferior to those of younger cohorts. This study demonstrates that older age in relation to hip arthroscopic surgery may contribute to a generally more difficult recovery, especially in the presence of osteoarthritis. The current study reflects these findings, demonstrating that mHHS values for younger patients were significantly greater than for older patients (P = .0148). The persistent, chronic hip pain that this population experiences may lead to additional complications, including a delay in return to sexual activity. Taken together, this information suggests that while patients undergoing hip arthroscopic surgery for FAI generally perform well postoperatively, it may be prudent to advise female and older patients that their recovery for sexual activity may be longer and less complete as compared with male and younger patients. While the current study demonstrates that sexual difficulties are prevalent among patients undergoing hip
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arthroscopic surgery, a relatively small proportion of these patients reported receiving any advice on this issue (28.1%). These patients independently raised the topic, as sexual function is not routinely discussed in the preoperative or postoperative period. Additionally, a reasonably high number of patients provided unsolicited comments in relation to the subject, potentially demonstrating sexual difficulties in relation to hip arthroscopic surgery and FAI may be underestimated by clinicians. These comments also suggest that patients may tend to not freely discuss these issues with the physician unless prompted. Dahm et al8 underlined the lack of importance given to the subject by 80% of practitioners who rarely, if ever, discussed sexual activity after THA with their patients. In addition, of surgeons who stated that they did discuss this topic, 96% spent 5 minutes or less.8 In a retrospective study, Wall et al30 found that only 36% of surgeons inquired preoperatively if symptoms were interfering with patients’ sex lives, and only 39% provided written information about sexual activity after THA. Only 25% of surgeons regularly advised patients about an appropriate time to resume sexual activity.30 In the current study’s cohort, a majority of patients noted that they would respond positively to a discussion with their surgeon (77.4%) or to receiving a booklet or handout about the subject (67.4%). Sexual function is a sensitive topic to discuss, but this study suggests that it is an important issue for patients with symptomatic FAI undergoing hip arthroscopic surgery and that physicians’ advice on appropriate expectations would be beneficial. There has been a significant trend toward utilizing patient-reported outcome scores in the evaluation of a patient’s quality of life and functional outcomes with hip arthroscopic surgery. However, the patient-reported outcome surveys commonly utilized by hip arthroscopic surgeons rarely take into account sexual functionality. Questionnaires such as the Copenhagen Hip and Groin Outcome Score, Hip Outcome Score, mHHS, Nonarthritic Hip Score, and International Hip Outcome Tool (iHOT-33) thoroughly analyze activities of daily living and sport-specific activities, but only the iHOT-33 contains a single question in relation to sexual difficulties.16,20,29 Also, even while this question exists, functional outcome surveys are typically analyzed as an aggregate, only utilizing the final score for clinical purposes and decision making. The current study found that mHHS values were negatively correlated with time to resumption of sexual activity (P = .002) and negatively correlated with time to sexual activity with minimal pain (P = .001). Additionally, patients reporting increased sexual frequency demonstrated higher mHHS values as compared with patients reporting decreased sexual frequency (P \ .0001). However, no significant correlations or relationships were found among the mHHS and other critical questions about sexual function such as continued postoperative sexual difficulties, whether sexual activity had been enjoyable, and whether the patient required changes in sexual positioning. While these findings show that the mHHS may be able to imply some aspects of postoperative sexual activity, they also support the notion that sexual activity may be a unique functional aspect that is not sensitively evaluated by outcome scores. While
sexual function may be indirectly related to other questions on these surveys, it is a unique issue that may be better evaluated separately to better detect its presence and to provide more appropriate management.
Limitations This study has several limitations including its retrospective nature utilizing an anonymous questionnaire sent by physical mail, significantly limiting its effect. A prospective study directly interviewing each patient would entail less methodological bias; however, this design also introduces unique problems as well. The current study is a retrospective, level 4 case series study, a study type that is susceptible to overinflating effects and differences being reported.13 However, the advantage of the current study’s methodology includes anonymity, allowing patients to more freely and honestly answer questions on this sensitive topic. Conversely, this process only allows for 1-way communication from the study staff toward the patient, omitting any potential clarification of questions. The retrospective nature of this study also limits the conclusions that could be made from the collected data. Significant recall bias exists as the accuracy of patient recollection cannot be guaranteed. Self-selection bias may also exist as it was under the patients’ own prerogative to complete and return the questionnaire. It is possible that patients demonstrating sexual difficulties were more likely to respond to the questionnaire, resulting in overreporting of sexual difficulties in this study. The current study achieved a response rate of 43% as compared with similar studies in the literature that reported response rates ranging from 33% to 86%. While the current study’s response rate may appear below average, the population in question must be accounted for and put into perspective. The mHHS utilized in this study has a large ceiling effect and limited psychometric properties as well as content validity for this patient population. This patientreported outcome score was selected for its brevity as it had the least amount of questions as compared with other commonly utilized questionnaires for the hip, while still containing sufficient content to analyze general functional outcomes for this study population. Additionally, this study did not reference ‘‘normal’’ sexual function in this age group as a control group was not available. Finally, this study had a minimum follow-up of 1 year, which may be too short a duration to adequately assess clinical outcomes. However, based on prior similar studies assessing different surgical procedures, the vast majority of patients resume sexual activity well within 1 year after surgery, and often within several months, and thus, we felt a 1-year time period was appropriate for the purposes of assessing sexual activity in this study.
CONCLUSION This study demonstrates the prevalence of sexual difficulties among the majority of patients with symptomatic FAI, the significant effect that these difficulties may have on quality
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of life, and the ability for hip arthroscopic surgery to improve sexual function postoperatively. While further studies are required to elucidate what specific factors are associated with sexual difficulties, the current study suggests that this is an important topic to explore.
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