The impact of surgery for trochanteric femur fracture on sexuality in men and their female partners

Abstract

Purpose:

This study was aimed to investigate the effects of trochanteric femur fracture treatment methods on erectile functions of the patients and on sexual functions with their female partners.

Materials and Methods:

A total of 43 patients with trochanteric femur fracture who underwent proximal femoral nail (PFN) or proximal femur locking compression plate (PF-LCP) surgery were included in the study. The PFN implant was applied to group 1 (n = 23) and the PF-LCP implant to group 2 (n = 20). All the patients and their female partners completed the 5-item version of the International Index of Erectile Function (IIEF-5) and the Female Sexual Function Index (FSFI) preoperatively and at 1 year postoperatively after the rehabilitation period.

Results:

The mean preoperative IIEF-5 and FSFI score was 21.910.9 and 21.911.1, 72.319.7 and 70.516.2 for the PFN and PF-LCP treatment groups, respectively, and at postoperative 1 year after rehabilitation, change in IIEF-5 score and FSFI score of each group was −6.512.1 versus −3.811.6, (p < 0.001) and −16110.7 versus −6.314, (p = 0.001), respectively.

Conclusion:

These data show that trochanteric femur fractures treated with PFN or PF-LCP had a negative impact on sexual function. PF-LCP had a greater negative effect than PFN on sexual function.

Introduction

Erectile dysfunction (ED) is defined as the persistent inability to achieve and maintain a sufficient erection for a satisfactory sexual performance. ¹ Although ED is not a life-threatening condition, it is a widespread sociocultural problem; the frequency and severity of which increases with age and can cause serious psychological problems, damaging societal relationships, and the man’s own happiness and self-respect. All epidemiological studies indicate the relationship between ED and increasing age. Cigarette smoking, hypertension, diabetes mellitus, obesity and a sedentary lifestyle are significant risk factors for ED. There are many factors in the aetiology of ED, primarily vasculogenic, neurogenic hypercholesterolemia, hormonal, cavernosal and psychogenic reasons. ²

ED along with urinary incontinence is a common consequence of the pelvic fracture, especially combined with the damage of posterior urethra. ED develops in 20–60% of these cases. ³ It is necessary to remember that ED may occur even in the absence of primary urological injuries. According to Flint and Cryer, sexual dysfunctions are the result of the primary lesion of the pudendal nerve or supplying blood vessels, which often remain undiagnosed during the initial stages of treatment. ⁴ To our knowledge, there has been no published study on the effects on sexual life of different treatment choices for fractures in this region.

In the current study, we evaluated sexuality in men who have undergone either proximal femoral nail (PFN) or proximal femur locking compression plate (PF-LCP) and their female partners.

Materials and methods

This study included 43 patients with trochanteric femur fracture who underwent either PFN or PF-LCP surgery according to the inclusion and exclusion criteria described below. This study was approved by the Institutional Review Board (ANEAH=E14-143) and written informed consent was obtained from each patient and their female partner. Patients were randomized before the operation by generating random numbers with Microsoft Excel 2007 (Microsoft Corporation, Seattle, Washington, USA). The PFN implant was applied to group 1 (n = 23) and the PF-LCP implant to group 2 (n = 20). In group 2, four patients did not complete the follow-up program. Among 39 patients that completed follow-up, according to AO classification, 4 patients had 31.A1, 13 patients had 31.A2 and 6 patients had 31.A3 type fracture in group 1 and 3 patients had 31.A1, 10 patients had 31.A2 and 3 patients had 31.A3 type fracture in group 2. All the operations with PFN were performed by the same surgeon with the same surgical technique and all operations with PF-LCP were performed by the same surgeon (D.C.) with the same surgical technique in all patients.

During the PFN surgery, a Biomet™ Peritrochanteric Nail System (Biomet Inc., Warsaw, Indiana, USA) was implanted using the same surgical technique in all patients. The patients were positioned in the supine position on a surgery table. A traction table was not used for any of the patients and reduction in the fracture was provided by manual longitudinal traction. The reduction was confirmed using a C-arm fluoroscope (GE Healthcare OEC 850). The PFN was inserted after a classical 4-cm entry incision 4–5 cm proximal to the trochanteric tip. A single static distal locking screw was inserted through the nail guide (Figure 1).

Figure 1.

Proximal femoral nail.

During the PF-LCP surgery, Synthes™ LCP Proximal Femoral Plate (Synthes, West Chester, Pennsylvania, USA) was implanted using the same open surgical technique and minimal invasive surgery was not performed in any patient. The patients were positioned in the supine position on a surgery table. A lateral longitudinal incision of 8–10 cm was made approximately 2 cm below the tip of the greater trochanter. After the longitudinal incision of the skin and subcutaneous tissue, the fascia of the vastus lateralis was split from its proximal insertion, and the muscle was flipped to visualize the lateral aspect of the proximal femur. After successful reduction of the fracture, the plate was placed on the lateral aspect of the proximal femur (Figure 2).

Figure 2.

Proximal femur locking compression plate.

All the patients completed the 5-item version of the International Index of Erectile Function (IIEF-5) ⁵ preoperatively and at postoperative first year. On the basis of the IIEF-5, ED severity was classified into 5 categories: severe (1–7), moderate (8–11), mild to moderate (12–16), mild (17–21) and without ED (22–25). On the day of the operation and postoperative first year, their female partners were also asked to complete the Female Sexual Function Index (FSFI), described by Rosen et al. ⁶ This is a 19-item self-report instrument assessing 6 domains of sexual function that measure sexual desire (score range, 2–10), arousal (score range, 0–20), lubrication (score range, 0–20), orgasm (score range, 0–15), satisfaction (score range, 2–15) and pain (score range, 0–15). The overall score of sexual functional status in the female partners was calculated as described previously.

In all patients, perioperative antibiotic prophylaxis using a first-generation cephalosporin was administered to prevent infection and the same analgesic treatment was given to reduce pain. Low-dose low-molecular-weight heparin was administered to prevent deep vein thrombosis. Patients in both groups were mobilized and allowed to perform quadriceps strengthening exercises the day after surgery. Postoperatively, the PFN patients were allowed toe-touch weight bearing just after surgery and weight as tolerated at 2 months, and PF-LCP patients were allowed toe-touch weight bearing for the first 8 weeks and weight as tolerated at 4 months.

The inclusion criteria were sexually active (IIEF-5 score ≥21) patients who had isolated trochanteric femur fracture. The exclusion criteria were rheumatological joint diseases, previous hip surgery on the fractured side, any other concomitant fracture, the need for the open technique in PFN surgery and any degree of ED (IIEF-5 score <21). None of the patients had a history of any malignancy or cardiac surgery.

Statistical analysis

Statistical analysis was performed with the Statistical Package for Social Sciences (SPSS, Chicago, Illinois, USA) for Windows Version 13.0 Software. Paired-samples t test was used for all the statistical analyses. A p value less than 0.05 was considered as statistical significant.

For post hoc calculation of statistical power in the t test for IIEF-5 changes in each group, we used the G*Power 3.0.10 software (Franz Faul, Universität Kiel, Germany). The power was calculated as 0.99 (effect size 1.44, α = 0.05, two-tailed).

Results

The mean ages of the male patients and their female partners were 48.2 ± 3.6 (range; 42–55) years and 44 ± 3.2 (range; 38–50) years, respectively. At the time of presentation, no statistical difference was detected in age (p = 0.456) and body mass index (30.1 vs. 29.3, p = 0.155) between the groups. Regarding the fracture type, there was no difference between the groups (p = 0.187).

The mean preoperative IIEF-5 scores were 21.9 ± 0.9 (range; 21–23) and 21.9 ± 1.1 (range; 21–25), for the PFN and PF-LCP treatment groups, respectively (p = 0.416). At postoperative first year, the mean IIEF-5 scores were 18.1 ± 1.8 (range; 14–21) in the PFN group and 15.4 ± 2.2 (range; 13–21) in the PF-LCP group. A statistically significant difference was determined between the postoperative IIEF-5 scores between the groups (p = 0.001). When the change in IIEF-5 score of each group was compared, the decrease in the PF-LCP group was found to be statistically significantly greater than in the PFN group (−6.5 ± 2.1 vs. −3.8 ± 1.6, p < 0.001).

The mean preoperative FSFI scores of the female partners were 72.3 ± 9.7 (range; 54–86) in the PFN group and 70.5 ± 6.2 (range; 60–82) in the PF-LCP treatment group (p = 0.495). At postoperative first year, the female partners were determined with a mean FSFI score of 65.9 ± 11.9 (range; 45–82) in the PFN group and 54.5 ± 13.2 (range; 37–80) in the PF-LCP group (p = 0.008). When the change in FSFI score of each group was compared, the decrease in the PF-LCP group was found to be statistically significantly greater than in the PFN group (−16 ± 10.7 vs. −6.3 ± 4, p = 0.001).

Discussion

The frequency of ED increases with age and is seen as a widespread health problem throughout the world. In the United States, the Massachusetts Male Aging Study questioned 1709 males about ED, firstly in 1987–1989, then in 1995–1997. The prevalence of any degree of ED between the ages of 40 and 70 years was found to be 52.1%, with the rates for mild, moderate and severe ED determined as 17.2%, 25.2% and 9.6%, respectively. ⁷

There are many factors in the aetiology of ED and some of these factors are encountered as orthopaedic reasons, the leading one of these being pelvic fractures. A study ⁸ showed higher percentage of sexual dysfunction in patients with pelvic fractures compared to patients without pelvic fracture (21% and 14%, respectively) at 1 year after the injury. Moreover, in the case of sacroiliac fractures, there is higher risk of sexual and ejaculatory dysfunctions. Pavelka et al. claimed that the quality of life is significantly decreased in patients with sexual dysfunction after pelvic trauma. ³ In a study by Malavaud et al., ⁹ 46 patients with pelvic fracture were examined and it was determined that 29.7% had lost erectile functions. The reasons for ED in those patients could have been vasculogenic, neurogenic, corporeal or psychogenic. Shenfeld and co-workers ¹⁰ reported on a series of patients, 72% of whom had a neurogenic cause of ED, using penile duplex ultrasonography, arteriogram and response to intracavernous vasoactive injection. Vasculogenic aetiology was implicated in the other 28% of patients as they showed an abnormal arterial response during duplex ultrasonography. Asci et al. ¹¹ reported penile vascular insufficiency as the major aetiological factor causing ED in patients with pelvic fracture. Mark et al. ¹² suggested a neurogenic aetiology due to the frequent association of sexual dysfunction with pubic rami fractures and the relation of this fracture pattern to cavernous nerve damage. A 89% response rate to intracavernous vasoactive injection further supported a neurogenic aetiology in these patients. In order to evaluate the various aspects of sexual function in men after pelvic fracture, the retrospective study including patients with pelvic fractures admitted to the relevant department from 1995 to 2001 was conducted by Metze and associates. ¹³ The evaluation was done using the IIEF scale. About 61% of patients reported limitations in their sexual functions. Persistent ED was found in 19% of cases. The authors found that the damages to the symphysis increase the risk of temporary EDs. Comparison of compression and distraction of the urethra showed that patients with distraction suffer from more severe sexual dysfunction. Damages of the posterior part of the pelvic ring increase the risk of persistent problems, which is probably associated with nerve damage. The authors concluded that the IIEF questionnaire should be applied to all patients during the period of rehabilitation in order to identify patients who need further medical care.

In patients treated for trochanteric femur fracture, ED may occur after treatment. In the international literature, published studies related to ED occurring after trochanteric femur fractures are generally in the form of case reports. ^14,15 The most extensive series was reported by Mallet et al. ¹⁶ in which patients with 37 femoral shaft fractures and 32 tibial shaft fractures treated with intramedullary nailing were evaluated. The study concluded that a significantly greater proportion of patients had impaired erectile function (mild to moderate, moderate and severe ED, IIEF-5 score <21) after femoral fracture than after tibial fracture (40.5% vs. 12.5%, p < 0.01). The authors concluded that the high prevalence of ED after femoral shaft fracture treated by intramedullary nailing was due to a selective impact on rigidity maintenance.

Prolonged perineal traction used in the surgical treatment of femoral fractures is implicated as a causative factor in transient ED. Diminution in vascularity and hence ischemia to the nerves owing to compression of the perineum may also contribute to the neuropraxia, which is thought to be a causal factor. ¹⁷ Studies from cadaver dissections have revealed that the pudendal nerve is skeletally protected from external injury by the ischial tuberosity and the inferior pubic ramus but becomes vulnerable to perineal injury distally after its trifurcation in the perineum. ¹⁴ Therefore, it is likely that neuropraxia was secondary to counter traction provided by the perineal post which allows internal fixation on the fracture table. It is not possible to accurately measure the exact amount of weight used to reduce a femoral fracture using modern fracture tables. The amount of traction weight and time for which it is applied is variable and depends on the nature of the fracture. Rudge ¹⁸ has shown that continuous pressure of 1.4 kg/cm² for 90 min can cause a nerve conduction block, which can be complete and permanent. It has been estimated that the actual traction pressure exerted on the perineal region is greater than 1.4 kg/cm², placing the perineal nerves involved in the erectile mechanism at risk of injury as well as other injuries such as urethral tears.

Our results showed that some of the patients operated on for trochanteric femur fracture developed impaired erectile functions and this also had a negative effect on the sexual functions of their female partners. In the current study, the operations were short in duration, only manual traction was applied and a traction table was not used and in the placement of PFN, by not allowing excessive distraction of the fracture region, potential rigidity was avoided. While a mean drop of 3.8 points was determined in the IIEF-5 score of the PFN group, the mean decrease in the PF-LCP group was 6.5 points. This may be due to a much larger incision being used in PF-LCP surgery and more damage due to significantly more dissection of the hip muscle groups. In addition, the rehabilitation period after PF-LCP operation was longer (4 months vs. 2 months) and that the larger scar could have a negative psychological effect which could be another reason for impaired sexual functions. Parallel to the male patients, the sexual functions of the female partners were less affected in the PFN group.

There are limitations to the present study. Treatment with PF-LCP was only applied with open surgery so there is no information about plating made with a minimally invasive technique. Secondly, the results are only short term. In addition, as the traction table was not used for any of the patients, there was no evaluation of the effect on sexual functions following the surgical treatment of these fractures using a traction table. Finally, as all the patients in this study were male, it was not possible to report on the postoperative sexual functions of female patients from the two different implants used in the study for the surgical treatment of trochanteric femur fractures.

Conclusion

Our results show that trochanteric femur fractures treated with PFN or PF-LCP had a negative impact on erectile function. PF-LCP had a greater negative effect than PFN on erectile function. Moreover, the sexual function of the female partner was affected by male erection status after operation. Therefore, postoperative ED in male patients should be taken into consideration for concomitant female sexual dysfunction. Furthermore, lengthy use of the traction table and distraction in the fracture site should be avoided during surgery. The main clinical relevance of the present study is that the difference in postoperative sexual life quality between the PFN and PF-LCP should be considered by surgeons when treating a trochanteric femur fracture.