Eur J Orthop Surg Traumatol DOI 10.1007/s00590-014-1432-1
ORIGINAL ARTICLE
Quality of sexual life after total hip arthroplasty in male patients with osteonecrosis of femoral head Bai-Liang Wang • De-Bo Yue • Bao Xing Liu Wan-Shou Guo
•
Received: 16 January 2014 / Accepted: 11 February 2014 Ó Springer-Verlag France 2014
Abstract Background Patients with osteonecrosis of the femoral head (ONFH) have a severe impact on their health status, functionality and quality of life. Sexual life is an important component of the quality of life and is still a frequently neglected domain in patients with ONFH. The aims of the study were to evaluate the influence of the disease and the total hip arthroplasty (THA) surgery on quality of sexual life (QSL) in these patients. Methods A prospective, self-controlled study was done. 247 patients of ONFH who underwent unilateral or bilateral THA were asked to complete a standardized QSL questionnaire, and the score of QSL was evaluated preoperatively and at first year follow-up of post-THA operation. Results The mean age of the patient was 46.8 (range 25–60) years. 194 cases (78.5 %, 276 hips) were alcoholinduced ONFH. There is significant decrease (p = 0.026) in sexual relationship impairment on the 0–8 scale from pre-THA (5.3 ± 0.7) to post-THA (2.3 ± 0.4). There is no significant difference for effect on sexual function (p = 0.14) between pre-THA (2.3 ± 0.4) and post-THA (1.8 ± 0.3). There is significant improvement (p = 0.018) in overall sexual satisfaction degree of patients on the 1–5 scale from pre-THA (2.7 ± 0.2) to post-THA (4.7 ± 0.6), but no significant increase for sexual partner. Conclusion ONFH has impaired relationships with partner and overall sexual satisfaction degree of the male B.-L. Wang (&) D.-B. Yue W.-S. Guo Department of Joint Surgery, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Hepingli, Beijing 100029, China e-mail: [email protected] B. X. Liu Department of Andrology, China-Japan Friendship Hospital, Beijing, China
patients; THA has improved significantly relationships with partner and overall sexual satisfaction degree of the male patients, but no effect on sexual function of the patients and overall sexual satisfaction degree of sexual partner. Keywords Sexual life Total hip arthroplasty Osteonecrosis
Introduction Osteonecrosis of the femoral head (ONFH) is a debilitating disease that often leads to destruction of the hip joint in later stage of the disease. Patients with ONFH are typically younger, more active, and ONFH can have a severe impact on a patient’s health status, functionality and quality of life [1–4]. Pain and restricted movement not only affect everyday activities, but may have a profound effect on the sexual life of patients so afflicted. Sexual life is an important component of the quality of life and is still a frequently neglected domain in patients with ONFH [2, 5]. Total hip arthroplasty (THA) remains an effective tool for the treatment of patients with end-stage ONFH. The value of THA in improving quality of life in general is confirmed by many studies, as regards postoperative pain, hip mobility, and walking distance [2, 3, 5–7]. A few investigators have addressed the role that THA plays in improving sexual function in women [8, 9]. In China, males have a higher incidence of ONFH than female due to drinking customs [10–13]. There are few studies concerning quality of sexual life (QSL) in male patients with ONFH. The aims of the study were to evaluate QSL comparing pre- and post-THA in male patients with ONFH, to determine the influence of the disease and the THA surgery on QSL in these patients.
123
Eur J Orthop Surg Traumatol
Materials and methods Patients A prospective, self-controlled study was done. During the period from April 2011 to March 2013, questionnaire was presented to 300 patients who underwent unilateral or bilateral THA for later-stage ONFH and were eligible for this study at our hospital. All sexually active (at least one sexual intercourse per month was accepted as the criterion of sexual activity) married adult male ONFH patients (more than 25 years old and younger than 60 years) diagnosed according to the system of the association research circulation osseous criteria [1, 8] were included in the study. Exclusion criteria included severe comorbidities affecting heart, lung, liver or kidneys, patients under medications such as antidepressants, psychiatric history, and having mental retardation. The aim of the study was explained to each patient, and informed consent to participate was obtained in writing. The work has been approved by ChinaJapan Friendship hospital Ethics Committee. All surgical procedures were performed by the same medical team composed of senior surgeons through the posterolateral approach. The same brand of THA (Depuy Johnson and Johnson, Warsaw, IN, USA) was implanted. 247 patients of ONFH who underwent unilateral or bilateral THA were asked to complete a standardized QSL questionnaire, and the score of QSL was evaluated preoperatively and at first year follow-up of post-THA operation. The Harris Score were recorded preoperatively and at follow-up. Finally, 247 cases were available for study. The demographic and disease profiles of the patients were listed in Table 1. Evaluation of QSL In order to evaluate the preoperative and postoperative status of our patients, we asked them to complete a standardized self-administered questionnaire of eight questions according to the Body Image Questionnaire and the Chinese Index of Sexual Function for Premature Ejaculation Questionnaire [13, 14]. These questions concerned the effect of the hip disease on their sexual activities and the result of the surgery on the performance of those activities. For each question, participants provided ratings based on different scale. These topics related to (1) the magnitude of the effect of their current status on sexual relationship(s) with current partners (scale 0–8); (2) their current status on sexual function, including sexual enjoyment and frequency (scale 0–8); (3) the overall sexual satisfaction degree of patients (scale 1–5); (4) the overall sexual satisfaction degree of sexual partner(scale 1–5); (5) hip pain during intercourse (Visual Analogue Scale, VAS, scale 0–10); (6) hip mobility during intercourse (scale 1–5); (7)
123
Table 1 Clinical and demographic characteristics of the patients Variables
Data
Age (years)
46.8 ± 12.1 (mean ± SD)
Etiology (cases/hips)
247/341
Alcohol abuse
194 (78.5 %)/276
Steroid-induced
31 (12.6 %)/43
Post-traumatic
12 (5 %)/12
Other
10 (4 %)/10
Unilateral/bilateral (cases) Type of bearings (cases/hips)
153/94 247/341
Ceramic-on-Ceramic
186 (75.3 %)/264
Ceramic-on-highly cross-linked polyethylene
53 (21.5 %)/69
Metal-on-highly cross-linked polyethylene
8 (3 %)/8
Diameter of femoral head (cases/hips)
247/341
28 mm
3 (1 %)/3
32 mm
98 (39.7 %)/142
36 mm Length of time after surgery before resuming sexual intercourse (weeks)
146 (59.1 %)/196 15.2 ± 3.5
the length of time after surgery before resuming sexual intercourse. Statistical analysis The calculations were performed using the Statistical Package for Social Sciences software version 16.0 for Windows. Means, standard deviations and frequencies were calculated for general demographic and routine clinical data. Analysis of variance (ANOVA) was used for comparisons of the pre- and post-THA QSL score of the patients. Correlations between clinical and demographic characteristics of the patients and post-THA QSL score of the patients were investigated by the Spearman’s test. A statistically significant difference was defined as p \ 0.05.
Results The clinical and demographic characteristics of the patients are listed in Table 1. The mean age of the patient was 46.8 (range 25–60) years. 194 cases (78.5 %, 276 hips) were alcohol-induced ONFH. 186 cases (75.3 %, 264 hips) had been implanted ceramic-on-ceramic bearing. 244 cases (99 %, 338 hips) had been implanted over 28 mm diameter of femoral head, which is important for better hip function. The mean time of resuming first sexual intercourse after surgery was 15.2 ± 3.5 weeks (range 6–24). The Harris hip score increased from a preoperative average of 45.1 points (range 18–55) to 97.1 points (range 85–100) at
Eur J Orthop Surg Traumatol Table 2 Comparisons of the pre- and post-THA QSL and Harris hip score of the patients Variables
Pre-THA (n = 247)
Post-THA (n = 247)
p value
Harris hip scores
45.1 ± 7.3
97.1 ± 6.3 0.012*
Effect on relationships with partner (scale 0–8)
5.3 ± 0.7
2.3 ± 0.4 0.026*
Effect on sexual function (scale 0–8)
2.3 ± 0.4
1.8 ± 0.3 0.14
Overall sexual satisfaction degree of patients (scale 1–5)
2.7 ± 0.2
4.7 ± 0.6 0.018*
Overall sexual satisfaction degree of sexual partner (scale 1–5)
3.8 ± 0.3
4.3 ± 0.3 0.4
Hip pain during intercourse (scale 0–10)
6.5 ± 0.5
0.9 ± 0.2 0.009*
Hip mobility during intercourse (scale 0–5)
1.4 ± 0.2
4.1 ± 0.6 0.012*
QSL
Mean ± SD scored according to the scores, * p \ 0.005
follow-up time (Table 2). Patients after THA had significantly higher Harris hip score, which demonstrated that the patient had better hip function improvement. There is significant decrease (p = 0.026) in sexual relationship impairment on the 0–8 scale from pre-THA (5.3 ± 0.7) to post-THA (2.3 ± 0.4). Interestingly, there is no significant difference for effect on sexual function (p = 0.14) between pre-THA (2.3 ± 0.4) and post-THA (1.8 ± 0.3). The overall mean scores for ONFH patients regarding effect on sexual function on the 0–8 scale were similarly significantly lower. There is significant improvement (p = 0.018) in overall sexual satisfaction degree of patients on the 1–5 scale from pre-THA (2.7 ± 0.2) to post-THA (4.7 ± 0.6), but no significant increase for sexual partner. Hip pain during intercourse (scale 0–10) after THA had significant decrease (p = 0.009) from pre-THA (6.5 ± 0.5) to post-THA (0.9 ± 0.2); moreover, the patient had got greater hip mobility during intercourse (scale 1–5) from pre-THA (1.4 ± 0.2) to post-THA (4.1 ± 0.6) (p = 0.009; Table 2). The relations between QSL of the patients after THA and clinical, demographic characteristics of the patients in the male patients with ONFH were evaluated. Post-THA QSL score of the patients had no significant correlations with etiology, unilateral/bilateral, type of bearings, and diameter of femoral head (p [ 0.05).
Discussion ONFH, a relatively common disease in younger, active male patients in China, seemingly has a wide range of
etiologies and a poorly understood pathogenesis. Because the patients affected by ONFH are generally younger than patients with osteoarthritis of the hip, and given their long course, the quality of life of these patients can be predicted to deteriorate greatly with time [1, 10–12, 15]. Sexual function is an important component of quality of life. By the time ONFH had progressed to the stage requiring THA, sexual difficulties were reported in about two-thirds of younger patients [3, 5, 6, 15]. While psychological factors, pain, and medication certainly play a role in causing sexual dysfunction, mechanical factors such as loss of overall mobility, restricted range of motion of the hip joints, and fatigue have been implicated as important etiologic factors [5, 16, 17]. The opportunity to reduce pain and improve the mechanical factors offered by THA is an important advance in the orthopedic treatment of patients with ONFH. The current study is novel in which it assessed, by comparing pre- and post-THA in male patients with ONFH, the influence of the disease and the THA surgery on QSL in Chinese male ONFH patients. These findings should be considered in clinical settings, where sexual health is often overlooked during the treatment of physical symptoms. Most of the studies were related to sexual quality of life of inflammatory arthropathy such as ankylosing spondylitis (AS) and rheumatoid [16–20]. Pirildar et al. [21] reported that patients with AS have significantly lower erectile function, orgasmic function, intercourse satisfaction and overall satisfaction scores compared with healthy controls, although the sexual desire score was not significantly lower. In another study, it was observed that sexual dysfunction is more frequent in men with AS compared to healthy controls, except in the ‘ejaculation problem’ domain [22]. To the best of our knowledge, until now, no study evaluated QSL in male patients with ONFH. Our studies suggested that ONFH has negative impact on relationships with sexual partners and no effect on sexual function. The underlying cause of disturbed sexual function is multifaceted, though the physical aspects are most easily assessed. It has been previously reported that psychological factors had great impact on sexual function in both genders [5, 23]. The patients with chronic inflammatory arthropathy usually have more psychological problems than ONFH patients, and there are big difference in psychological problems such as emotional and relational issues between women and men. Since then, a number of studies have addressed the issue of sexually active patients with different forms of hip disease and the effect of THA in resolving sexual difficulties [6, 24, 25]. These difficulties were more common and more severe in the women, usually due to hip pain and stiffness rather than a loss of libido [5, 19]. The value of THA in improving quality of life in general is confirmed by our Harris results, as regards postoperative pain, hip
123
Eur J Orthop Surg Traumatol
mobility, and walking distance. In addition, its role in helping to restore an improved sex life, which has been noted by others [3, 5, 7, 24], is also supported by our results. The QSL score of the patients and associations between post-THA QSL score of the patients and clinical, demographic characteristics of the patients in Chinese male ONFH patients were examined, revealing that ONFH has impaired sexual health and partner relationships, and THA has improved significantly overall sexual satisfaction degree of patient. Hip pain during sexual intercourse significantly decreased from 6.6 to 0.9 score, and hip mobility significantly increased during intercourse after THA surgery. However, our study revealed ONFH has certain effect on overall sexual satisfaction degree of sexual partner, and THA has not significantly improved it. We thought the reasons were that ONFH has no effect on sexual function, and women sexual partner of the patients are healthy who can select favoring position. The time of resuming sexual intercourse was about 15 weeks after surgery. Information needs to be provided for those men who desired more information regarding sexual function postoperatively, and a booklet was written for patients and their partners specifically for this purpose. The results of correlation analysis in the current study demonstrated that post-THA QSL score of the patients had no significant correlations with etiology, unilateral/bilateral, type of bearings, and diameter of femoral head. It probably related to bias clinical and demographic characteristics of the patients: alcohol abuse (78.5 %), unilateral/ bilateral (153/94), Ceramic-on-Ceramic (75.3 %), and above 28 mm diameter of femoral head (99 %). The limitation of this study was that we may have overlooked the possible influence of psychological factors on the QSL of the patients. The other point is that information provided by questionnaire is unable to examine all facets of sexual activity in which we focused on sexual intercourse as an indicator of sexual satisfaction, and many patients are able to enjoy a rewarding sex life through noncoital activities.
Conclusion ONFH has impaired relationships with partner and overall sexual satisfaction degree of the male patients; THA has improved significantly relationships with partner and overall sexual satisfaction degree of the male patients, but no effect on sexual function of the patients and overall sexual satisfaction degree of sexual partner. The time of resuming sexual intercourse was about 15 weeks after THA surgery, and post-THA QSL score of the patients had no significant correlations with etiology, unilateral/bilateral, type of bearings, and diameter of femoral head.
123
Acknowledgments This work was supported by Youth Foundation of China-Japan Friendship Hospital: No 2013-QN-17. Conflict of interest
The authors declare no conflicting interests.
References 1. Hungerford DS (2007) Treatment of osteonecrosis of the femoral head. J Arthroplast 22(4 Suppl):91–94 2. Kim SM, Lim SJ, Moon YW et al (2013) Cementless modular total hip arthroplasty in patients younger than fifty with femoral head osteonecrosis: minimum fifteen-year follow-up. J Arthroplast 28(3):504–509 3. Dosanjh S, Matta JM, Bhandari M (2009) The final straw: a qualitative study to explore patient decisions to undergo total hip arthroplasty. Arch Orthop Trauma Surg 129(6):719–727 4. Johannson HR, Zywiel MG, Marker DR et al (2011) Osteonecrosis is not a predictor of poor outcomes in primary total hip arthroplasty: a systematic literature review. Int Orthop 35(4): 465–473 5. Meyer H, Stern R, Fusetti C et al (2003) Sexual quality-of-life after hip surgery. J Orthopaed Traumatol 4:21–25 6. Hirvonen J, Blom M, Tuominen U et al (2006) Health-related quality of life in patients waiting for major joint replacement. A comparison between patients and population controls. Health Qual Life Outcomes 19(4):3 7. Tuominen U, Blom M, Hirvonen J et al (2007) The effect of comorbidities on health-related quality of life in patients placed on the waiting list for total joint replacement. Health Qual Life Outcomes 15(5):16 8. Stern SH, Fuchs MD, Ganz SB et al (1991) Sexual function after total hip arthroplasty. Clin Orthop 269:228–235 9. Monaghan J, Lenehan P, Stronge J et al (1987) Pregnancy and vaginal delivery following bilateral total hip replacement. Eur J Obstet Gynecol Reprod Biol 26:261–264 10. Mont MA, Zywiel MG, Marker DR et al (2010) The natural history of untreated asymptomatic osteonecrosis of the femoral head: a systematic literature review. J Bone Joint Surg Am 92(12):2165–2170 11. Wang BL, Sun W, Shi ZC et al (2010) Treatment of nontraumatic osteonecrosis of the femoral head with the implantation of core decompression and concentrated autologous bone marrow containing mononuclear cells. Arch Orthop Trauma Surg 130(7): 859–865 12. Wang BL, Sun W, Shi ZC et al (2010) Treatment of nontraumatic osteonecrosis of the femoral head using bone impaction grafting through a femoral neck window. Int Orthop 34:635–639 13. Shen B, Zhang A, Liu J et al (2013) A primary analysis of sexual problems in Chinese patients with ankylosing spondylitis. Rheumatol Int 33(6):1429–1435 14. Yuan YM, Xin ZHC, Jin TY et al (2003) Chinese index of sexual function for premature ejaculation (CIPE):a multidimensional scale for assessment of premature ejaculation. Chin J Androl 17(5):302–306 15. Seki T, Hasegawa Y, Masui T et al (2008) Quality of life following femoral osteotomy and total hip arthroplasty for nontraumatic osteonecrosis of the femoral head. J Orthop Sci 13(2):116–121 16. Sariyildiz MA, Batmaz I, Dilek B et al (2013) Relationship of the sexual functions with the clinical parameters, radiological scores and the quality of life in male patients with ankylosing spondylitis. Rheumatol Int 33(3):623–629 17. Cakar E, Dincer U, Kiralp MZ et al (2007) Sexual problems in male ankylosing spondylitis patients: relationship with
Eur J Orthop Surg Traumatol
18.
19.
20.
21.
functionality, disease activity, quality of life, and emotional status. Clin Rheumatol 26(10):1607–1613 Ito H, Matsuno T, Hirayama T, Tanino H et al (2007) Healthrelated quality of life in patients with systemic lupus erythematosus after medium to long-term follow-up of hip arthroplasty. Lupus 16(5):318–323 Demir SE, Rezvani A, Ok S (2013) Assessment of sexual functions in female patients with ankylosing spondylitis compared with healthy controls. Rheumatol Int 33(1):57–63 Quaresma MR, Goldsmith CH, Lamont J et al (1997) Assessment of sexual function in patients with rheumatic disorders: a critical appraisal. J Rheumatol 24(9):1673–1676 Pirildar T, Muezzinoglu T, Pirildar S (2004) Sexual function in ankylosing spondylitis: a study of 65 men. J Urol 171(4): 1598–1600
22. Dincer U, Cakar E, Kiralp MZ et al (2007) Assessment of sexual dysfunction in male patients with ankylosing spondylitis. Rheumatol Int 27:561–566 23. Baysal O, Durmus B, Ersoy Y et al (2011) Relationship between psychological status and disease activity and quality of life in ankylosing spondylitis. Rheumatol Int 31:795–800 24. Wright JG, Rudicel S, Feinstein AR (1994) Ask patients what they want. Evaluation of individual complaints before total hip replacement. J Bone Joint Surg Br 76:229–234 25. Gutweniger S, Kopp M, Mur E et al (1999) Body image of women with rheumatoid arthritis. Clin Exp Rheumatol 17:413–417
123
ORIGINAL ARTICLE
Quality of sexual life after total hip arthroplasty in male patients with osteonecrosis of femoral head Bai-Liang Wang • De-Bo Yue • Bao Xing Liu Wan-Shou Guo
•
Received: 16 January 2014 / Accepted: 11 February 2014 Ó Springer-Verlag France 2014
Abstract Background Patients with osteonecrosis of the femoral head (ONFH) have a severe impact on their health status, functionality and quality of life. Sexual life is an important component of the quality of life and is still a frequently neglected domain in patients with ONFH. The aims of the study were to evaluate the influence of the disease and the total hip arthroplasty (THA) surgery on quality of sexual life (QSL) in these patients. Methods A prospective, self-controlled study was done. 247 patients of ONFH who underwent unilateral or bilateral THA were asked to complete a standardized QSL questionnaire, and the score of QSL was evaluated preoperatively and at first year follow-up of post-THA operation. Results The mean age of the patient was 46.8 (range 25–60) years. 194 cases (78.5 %, 276 hips) were alcoholinduced ONFH. There is significant decrease (p = 0.026) in sexual relationship impairment on the 0–8 scale from pre-THA (5.3 ± 0.7) to post-THA (2.3 ± 0.4). There is no significant difference for effect on sexual function (p = 0.14) between pre-THA (2.3 ± 0.4) and post-THA (1.8 ± 0.3). There is significant improvement (p = 0.018) in overall sexual satisfaction degree of patients on the 1–5 scale from pre-THA (2.7 ± 0.2) to post-THA (4.7 ± 0.6), but no significant increase for sexual partner. Conclusion ONFH has impaired relationships with partner and overall sexual satisfaction degree of the male B.-L. Wang (&) D.-B. Yue W.-S. Guo Department of Joint Surgery, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Hepingli, Beijing 100029, China e-mail: [email protected] B. X. Liu Department of Andrology, China-Japan Friendship Hospital, Beijing, China
patients; THA has improved significantly relationships with partner and overall sexual satisfaction degree of the male patients, but no effect on sexual function of the patients and overall sexual satisfaction degree of sexual partner. Keywords Sexual life Total hip arthroplasty Osteonecrosis
Introduction Osteonecrosis of the femoral head (ONFH) is a debilitating disease that often leads to destruction of the hip joint in later stage of the disease. Patients with ONFH are typically younger, more active, and ONFH can have a severe impact on a patient’s health status, functionality and quality of life [1–4]. Pain and restricted movement not only affect everyday activities, but may have a profound effect on the sexual life of patients so afflicted. Sexual life is an important component of the quality of life and is still a frequently neglected domain in patients with ONFH [2, 5]. Total hip arthroplasty (THA) remains an effective tool for the treatment of patients with end-stage ONFH. The value of THA in improving quality of life in general is confirmed by many studies, as regards postoperative pain, hip mobility, and walking distance [2, 3, 5–7]. A few investigators have addressed the role that THA plays in improving sexual function in women [8, 9]. In China, males have a higher incidence of ONFH than female due to drinking customs [10–13]. There are few studies concerning quality of sexual life (QSL) in male patients with ONFH. The aims of the study were to evaluate QSL comparing pre- and post-THA in male patients with ONFH, to determine the influence of the disease and the THA surgery on QSL in these patients.
123
Eur J Orthop Surg Traumatol
Materials and methods Patients A prospective, self-controlled study was done. During the period from April 2011 to March 2013, questionnaire was presented to 300 patients who underwent unilateral or bilateral THA for later-stage ONFH and were eligible for this study at our hospital. All sexually active (at least one sexual intercourse per month was accepted as the criterion of sexual activity) married adult male ONFH patients (more than 25 years old and younger than 60 years) diagnosed according to the system of the association research circulation osseous criteria [1, 8] were included in the study. Exclusion criteria included severe comorbidities affecting heart, lung, liver or kidneys, patients under medications such as antidepressants, psychiatric history, and having mental retardation. The aim of the study was explained to each patient, and informed consent to participate was obtained in writing. The work has been approved by ChinaJapan Friendship hospital Ethics Committee. All surgical procedures were performed by the same medical team composed of senior surgeons through the posterolateral approach. The same brand of THA (Depuy Johnson and Johnson, Warsaw, IN, USA) was implanted. 247 patients of ONFH who underwent unilateral or bilateral THA were asked to complete a standardized QSL questionnaire, and the score of QSL was evaluated preoperatively and at first year follow-up of post-THA operation. The Harris Score were recorded preoperatively and at follow-up. Finally, 247 cases were available for study. The demographic and disease profiles of the patients were listed in Table 1. Evaluation of QSL In order to evaluate the preoperative and postoperative status of our patients, we asked them to complete a standardized self-administered questionnaire of eight questions according to the Body Image Questionnaire and the Chinese Index of Sexual Function for Premature Ejaculation Questionnaire [13, 14]. These questions concerned the effect of the hip disease on their sexual activities and the result of the surgery on the performance of those activities. For each question, participants provided ratings based on different scale. These topics related to (1) the magnitude of the effect of their current status on sexual relationship(s) with current partners (scale 0–8); (2) their current status on sexual function, including sexual enjoyment and frequency (scale 0–8); (3) the overall sexual satisfaction degree of patients (scale 1–5); (4) the overall sexual satisfaction degree of sexual partner(scale 1–5); (5) hip pain during intercourse (Visual Analogue Scale, VAS, scale 0–10); (6) hip mobility during intercourse (scale 1–5); (7)
123
Table 1 Clinical and demographic characteristics of the patients Variables
Data
Age (years)
46.8 ± 12.1 (mean ± SD)
Etiology (cases/hips)
247/341
Alcohol abuse
194 (78.5 %)/276
Steroid-induced
31 (12.6 %)/43
Post-traumatic
12 (5 %)/12
Other
10 (4 %)/10
Unilateral/bilateral (cases) Type of bearings (cases/hips)
153/94 247/341
Ceramic-on-Ceramic
186 (75.3 %)/264
Ceramic-on-highly cross-linked polyethylene
53 (21.5 %)/69
Metal-on-highly cross-linked polyethylene
8 (3 %)/8
Diameter of femoral head (cases/hips)
247/341
28 mm
3 (1 %)/3
32 mm
98 (39.7 %)/142
36 mm Length of time after surgery before resuming sexual intercourse (weeks)
146 (59.1 %)/196 15.2 ± 3.5
the length of time after surgery before resuming sexual intercourse. Statistical analysis The calculations were performed using the Statistical Package for Social Sciences software version 16.0 for Windows. Means, standard deviations and frequencies were calculated for general demographic and routine clinical data. Analysis of variance (ANOVA) was used for comparisons of the pre- and post-THA QSL score of the patients. Correlations between clinical and demographic characteristics of the patients and post-THA QSL score of the patients were investigated by the Spearman’s test. A statistically significant difference was defined as p \ 0.05.
Results The clinical and demographic characteristics of the patients are listed in Table 1. The mean age of the patient was 46.8 (range 25–60) years. 194 cases (78.5 %, 276 hips) were alcohol-induced ONFH. 186 cases (75.3 %, 264 hips) had been implanted ceramic-on-ceramic bearing. 244 cases (99 %, 338 hips) had been implanted over 28 mm diameter of femoral head, which is important for better hip function. The mean time of resuming first sexual intercourse after surgery was 15.2 ± 3.5 weeks (range 6–24). The Harris hip score increased from a preoperative average of 45.1 points (range 18–55) to 97.1 points (range 85–100) at
Eur J Orthop Surg Traumatol Table 2 Comparisons of the pre- and post-THA QSL and Harris hip score of the patients Variables
Pre-THA (n = 247)
Post-THA (n = 247)
p value
Harris hip scores
45.1 ± 7.3
97.1 ± 6.3 0.012*
Effect on relationships with partner (scale 0–8)
5.3 ± 0.7
2.3 ± 0.4 0.026*
Effect on sexual function (scale 0–8)
2.3 ± 0.4
1.8 ± 0.3 0.14
Overall sexual satisfaction degree of patients (scale 1–5)
2.7 ± 0.2
4.7 ± 0.6 0.018*
Overall sexual satisfaction degree of sexual partner (scale 1–5)
3.8 ± 0.3
4.3 ± 0.3 0.4
Hip pain during intercourse (scale 0–10)
6.5 ± 0.5
0.9 ± 0.2 0.009*
Hip mobility during intercourse (scale 0–5)
1.4 ± 0.2
4.1 ± 0.6 0.012*
QSL
Mean ± SD scored according to the scores, * p \ 0.005
follow-up time (Table 2). Patients after THA had significantly higher Harris hip score, which demonstrated that the patient had better hip function improvement. There is significant decrease (p = 0.026) in sexual relationship impairment on the 0–8 scale from pre-THA (5.3 ± 0.7) to post-THA (2.3 ± 0.4). Interestingly, there is no significant difference for effect on sexual function (p = 0.14) between pre-THA (2.3 ± 0.4) and post-THA (1.8 ± 0.3). The overall mean scores for ONFH patients regarding effect on sexual function on the 0–8 scale were similarly significantly lower. There is significant improvement (p = 0.018) in overall sexual satisfaction degree of patients on the 1–5 scale from pre-THA (2.7 ± 0.2) to post-THA (4.7 ± 0.6), but no significant increase for sexual partner. Hip pain during intercourse (scale 0–10) after THA had significant decrease (p = 0.009) from pre-THA (6.5 ± 0.5) to post-THA (0.9 ± 0.2); moreover, the patient had got greater hip mobility during intercourse (scale 1–5) from pre-THA (1.4 ± 0.2) to post-THA (4.1 ± 0.6) (p = 0.009; Table 2). The relations between QSL of the patients after THA and clinical, demographic characteristics of the patients in the male patients with ONFH were evaluated. Post-THA QSL score of the patients had no significant correlations with etiology, unilateral/bilateral, type of bearings, and diameter of femoral head (p [ 0.05).
Discussion ONFH, a relatively common disease in younger, active male patients in China, seemingly has a wide range of
etiologies and a poorly understood pathogenesis. Because the patients affected by ONFH are generally younger than patients with osteoarthritis of the hip, and given their long course, the quality of life of these patients can be predicted to deteriorate greatly with time [1, 10–12, 15]. Sexual function is an important component of quality of life. By the time ONFH had progressed to the stage requiring THA, sexual difficulties were reported in about two-thirds of younger patients [3, 5, 6, 15]. While psychological factors, pain, and medication certainly play a role in causing sexual dysfunction, mechanical factors such as loss of overall mobility, restricted range of motion of the hip joints, and fatigue have been implicated as important etiologic factors [5, 16, 17]. The opportunity to reduce pain and improve the mechanical factors offered by THA is an important advance in the orthopedic treatment of patients with ONFH. The current study is novel in which it assessed, by comparing pre- and post-THA in male patients with ONFH, the influence of the disease and the THA surgery on QSL in Chinese male ONFH patients. These findings should be considered in clinical settings, where sexual health is often overlooked during the treatment of physical symptoms. Most of the studies were related to sexual quality of life of inflammatory arthropathy such as ankylosing spondylitis (AS) and rheumatoid [16–20]. Pirildar et al. [21] reported that patients with AS have significantly lower erectile function, orgasmic function, intercourse satisfaction and overall satisfaction scores compared with healthy controls, although the sexual desire score was not significantly lower. In another study, it was observed that sexual dysfunction is more frequent in men with AS compared to healthy controls, except in the ‘ejaculation problem’ domain [22]. To the best of our knowledge, until now, no study evaluated QSL in male patients with ONFH. Our studies suggested that ONFH has negative impact on relationships with sexual partners and no effect on sexual function. The underlying cause of disturbed sexual function is multifaceted, though the physical aspects are most easily assessed. It has been previously reported that psychological factors had great impact on sexual function in both genders [5, 23]. The patients with chronic inflammatory arthropathy usually have more psychological problems than ONFH patients, and there are big difference in psychological problems such as emotional and relational issues between women and men. Since then, a number of studies have addressed the issue of sexually active patients with different forms of hip disease and the effect of THA in resolving sexual difficulties [6, 24, 25]. These difficulties were more common and more severe in the women, usually due to hip pain and stiffness rather than a loss of libido [5, 19]. The value of THA in improving quality of life in general is confirmed by our Harris results, as regards postoperative pain, hip
123
Eur J Orthop Surg Traumatol
mobility, and walking distance. In addition, its role in helping to restore an improved sex life, which has been noted by others [3, 5, 7, 24], is also supported by our results. The QSL score of the patients and associations between post-THA QSL score of the patients and clinical, demographic characteristics of the patients in Chinese male ONFH patients were examined, revealing that ONFH has impaired sexual health and partner relationships, and THA has improved significantly overall sexual satisfaction degree of patient. Hip pain during sexual intercourse significantly decreased from 6.6 to 0.9 score, and hip mobility significantly increased during intercourse after THA surgery. However, our study revealed ONFH has certain effect on overall sexual satisfaction degree of sexual partner, and THA has not significantly improved it. We thought the reasons were that ONFH has no effect on sexual function, and women sexual partner of the patients are healthy who can select favoring position. The time of resuming sexual intercourse was about 15 weeks after surgery. Information needs to be provided for those men who desired more information regarding sexual function postoperatively, and a booklet was written for patients and their partners specifically for this purpose. The results of correlation analysis in the current study demonstrated that post-THA QSL score of the patients had no significant correlations with etiology, unilateral/bilateral, type of bearings, and diameter of femoral head. It probably related to bias clinical and demographic characteristics of the patients: alcohol abuse (78.5 %), unilateral/ bilateral (153/94), Ceramic-on-Ceramic (75.3 %), and above 28 mm diameter of femoral head (99 %). The limitation of this study was that we may have overlooked the possible influence of psychological factors on the QSL of the patients. The other point is that information provided by questionnaire is unable to examine all facets of sexual activity in which we focused on sexual intercourse as an indicator of sexual satisfaction, and many patients are able to enjoy a rewarding sex life through noncoital activities.
Conclusion ONFH has impaired relationships with partner and overall sexual satisfaction degree of the male patients; THA has improved significantly relationships with partner and overall sexual satisfaction degree of the male patients, but no effect on sexual function of the patients and overall sexual satisfaction degree of sexual partner. The time of resuming sexual intercourse was about 15 weeks after THA surgery, and post-THA QSL score of the patients had no significant correlations with etiology, unilateral/bilateral, type of bearings, and diameter of femoral head.
123
Acknowledgments This work was supported by Youth Foundation of China-Japan Friendship Hospital: No 2013-QN-17. Conflict of interest
The authors declare no conflicting interests.
References 1. Hungerford DS (2007) Treatment of osteonecrosis of the femoral head. J Arthroplast 22(4 Suppl):91–94 2. Kim SM, Lim SJ, Moon YW et al (2013) Cementless modular total hip arthroplasty in patients younger than fifty with femoral head osteonecrosis: minimum fifteen-year follow-up. J Arthroplast 28(3):504–509 3. Dosanjh S, Matta JM, Bhandari M (2009) The final straw: a qualitative study to explore patient decisions to undergo total hip arthroplasty. Arch Orthop Trauma Surg 129(6):719–727 4. Johannson HR, Zywiel MG, Marker DR et al (2011) Osteonecrosis is not a predictor of poor outcomes in primary total hip arthroplasty: a systematic literature review. Int Orthop 35(4): 465–473 5. Meyer H, Stern R, Fusetti C et al (2003) Sexual quality-of-life after hip surgery. J Orthopaed Traumatol 4:21–25 6. Hirvonen J, Blom M, Tuominen U et al (2006) Health-related quality of life in patients waiting for major joint replacement. A comparison between patients and population controls. Health Qual Life Outcomes 19(4):3 7. Tuominen U, Blom M, Hirvonen J et al (2007) The effect of comorbidities on health-related quality of life in patients placed on the waiting list for total joint replacement. Health Qual Life Outcomes 15(5):16 8. Stern SH, Fuchs MD, Ganz SB et al (1991) Sexual function after total hip arthroplasty. Clin Orthop 269:228–235 9. Monaghan J, Lenehan P, Stronge J et al (1987) Pregnancy and vaginal delivery following bilateral total hip replacement. Eur J Obstet Gynecol Reprod Biol 26:261–264 10. Mont MA, Zywiel MG, Marker DR et al (2010) The natural history of untreated asymptomatic osteonecrosis of the femoral head: a systematic literature review. J Bone Joint Surg Am 92(12):2165–2170 11. Wang BL, Sun W, Shi ZC et al (2010) Treatment of nontraumatic osteonecrosis of the femoral head with the implantation of core decompression and concentrated autologous bone marrow containing mononuclear cells. Arch Orthop Trauma Surg 130(7): 859–865 12. Wang BL, Sun W, Shi ZC et al (2010) Treatment of nontraumatic osteonecrosis of the femoral head using bone impaction grafting through a femoral neck window. Int Orthop 34:635–639 13. Shen B, Zhang A, Liu J et al (2013) A primary analysis of sexual problems in Chinese patients with ankylosing spondylitis. Rheumatol Int 33(6):1429–1435 14. Yuan YM, Xin ZHC, Jin TY et al (2003) Chinese index of sexual function for premature ejaculation (CIPE):a multidimensional scale for assessment of premature ejaculation. Chin J Androl 17(5):302–306 15. Seki T, Hasegawa Y, Masui T et al (2008) Quality of life following femoral osteotomy and total hip arthroplasty for nontraumatic osteonecrosis of the femoral head. J Orthop Sci 13(2):116–121 16. Sariyildiz MA, Batmaz I, Dilek B et al (2013) Relationship of the sexual functions with the clinical parameters, radiological scores and the quality of life in male patients with ankylosing spondylitis. Rheumatol Int 33(3):623–629 17. Cakar E, Dincer U, Kiralp MZ et al (2007) Sexual problems in male ankylosing spondylitis patients: relationship with
Eur J Orthop Surg Traumatol
18.
19.
20.
21.
functionality, disease activity, quality of life, and emotional status. Clin Rheumatol 26(10):1607–1613 Ito H, Matsuno T, Hirayama T, Tanino H et al (2007) Healthrelated quality of life in patients with systemic lupus erythematosus after medium to long-term follow-up of hip arthroplasty. Lupus 16(5):318–323 Demir SE, Rezvani A, Ok S (2013) Assessment of sexual functions in female patients with ankylosing spondylitis compared with healthy controls. Rheumatol Int 33(1):57–63 Quaresma MR, Goldsmith CH, Lamont J et al (1997) Assessment of sexual function in patients with rheumatic disorders: a critical appraisal. J Rheumatol 24(9):1673–1676 Pirildar T, Muezzinoglu T, Pirildar S (2004) Sexual function in ankylosing spondylitis: a study of 65 men. J Urol 171(4): 1598–1600
22. Dincer U, Cakar E, Kiralp MZ et al (2007) Assessment of sexual dysfunction in male patients with ankylosing spondylitis. Rheumatol Int 27:561–566 23. Baysal O, Durmus B, Ersoy Y et al (2011) Relationship between psychological status and disease activity and quality of life in ankylosing spondylitis. Rheumatol Int 31:795–800 24. Wright JG, Rudicel S, Feinstein AR (1994) Ask patients what they want. Evaluation of individual complaints before total hip replacement. J Bone Joint Surg Br 76:229–234 25. Gutweniger S, Kopp M, Mur E et al (1999) Body image of women with rheumatoid arthritis. Clin Exp Rheumatol 17:413–417
123
