Abstract
Objectives:
Pudendal nerve palsy (PNP) is a poorly characterized but common postoperative complication of hip arthroscopy (HA) with a perineal post that can result in external genital numbness and sexual dysfunction in both men and women. Previous attempts to quantify the incidence of these symptoms have relied on patient-initiated reports, chart review, unvalidated questionnaires or have neglected the female experience altogether – failures which likely underestimate the incidence of this complication. We aimed to describe the incidence of postoperative PNP, the breadth of symptoms patient experience and their duration, as well as establish the relationship between PNP and table traction.
Methods:
We utilized a multisurgeon prospective cohort of HA patients a single academic center. All patients underwent primary unilateral hip arthroscopy, osteochondroplasty and labral repair in a supine position with a perineal post. Patients with preexisting PNP symptoms, including sexual dysfunction, and those who were not sexually active were excluded. Intraoperative traction duration and force were recorded using a Tekscan sensor applied to the perineal post. A PNP screening questionnaire and standardized, validated sexual function questionnaires were administered confidentially to patients at 2 weeks, 6 weeks, 3 months, and 6 months postoperatively. Patient-reported hip function scores (iHOT-33) were completed preoperatively and at 6 months postoperatively.
Results:
A total of 100 patients were enrolled. The mean age was 36.2 ± 9.4 years old, 56 patients (56%) were male. The mean traction duration was 80 ± 19 minutes. In the acute postoperative period, 77 patients (77%) experienced symptoms consistent with PNP. The most common sensory symptom described was perineal numbness (n = 77, 77%), followed by paresthesias (n=26, 26%). Seventeen men (17%) and 13 women (13%) reported symptoms of sexual dysfunction postoperatively, in the form of erectile dysfunction (men) or reduced sexual lubrication/dyspareunia/anorgasmia (women). Of patients who experienced PNP symptoms (n = 77), 21% had symptoms resolve by 6 weeks, 71% by 3 months, 90% by 6 months. Two male patients (3.6%) had persistent erectile dysfunction beyond 6 months postoperatively. Persistence of PNP symptoms beyond 6 weeks was associated with lower 33-item International Hip Outcome Tool (iHOT-33) scores at 6 months (mean difference: 18.4 [95% CI: 6.5-30.4], p = 0.003). Analysis of the calibrated sensor data to establish the relationship between traction force, pressure, and duration with PNP is pending.
Conclusions:
In this preliminary analysis of a planned 100-patient cohort, patients experienced a high rate of PNP and sexual dysfunction symptoms following HA with perineal post, far higher than previous reports. Most symptoms resolved within the first 3 months postoperatively. Anticipated results from the sensor data within this ongoing study are likely to provide insight into the relationship between traction force and/or duration and PNP incidence. A postless HA setup could be considered as an alternative given the described morbidity.