Hip Int 2014 ; 24 ( 1): 27- 31

DOI: 10.5301/hipint.5000077

Original Article

Periacetabular osteotomy: sporting, social and sexual
activity 9-12 years post surgery
Jakob Klit 1, Charlotte Hartig-Andreasen 2, Steffen Jacobsen 1, Kjeld Søballe 2, Anders Troelsen 1
1
2

Copenhagen University Hospital Hvidovre, Copenhagen - Denmark
Aarhus University Hospital, Aarhus - Denmark

Hip joint survivorship and functional outcome are traditional outcome measures applied after periacetabular osteotomy (PAO). Younger adults however have greater demands and expectations on the function of their hip joints and these demands are not expressed using traditional outcome assessment tools.
The main purpose of this study was to explore alternative functional and quality of life measure after PAO.
A cross sectional survey of preserved hip joints following PAO was performed. Fifty-two patients(68 hips), mean age 41 years (range 24-67), returned a questionnaire examining satisfaction, willingness to repeat surgery, quality of life, abilities in social activities, sports and sex-life, pain, limp, andstability of the hip.
Median satisfaction was 5 (range 1-5) and 44 of 49 patients were willing to repeat surgery. Significant improvements were seen in quality of life, ability to do sports, participate in social activities
and sex-life (p values <0.001) (although sex-life for males (p = 0.102)). Traditional outcomes (pain,stability and limp) showed significant improvements (p<0.001). Lasting improvements in patients’sex life, social life and ability to do sports nine to 12 years following PAO were reported. Such factors are important measures of outcome in a younger adult cohort.
Keywords: Hip, Health-related quality of life, Periacetabular osteotomy, Acetabular dysplasia,
Total hip arthroplasty, Femoral acetabular impingement
Accepted: June 7, 2013

INTRODUCTION
Since Wiberg’s thesis in 1939 many studies have confirmed the relationship between acetabular dysplasia andsecondary osteoarthritis (OA) in the young adult patient(1-6). In an attempt to prevent or postpone the development of OA in these patients, the periacetabular osteotomy (PAO) first described by Ganz et al, and latermodified, is used worldwide as a joint-preserving procedure (6-19). By reorientation of the acetabulum andincreasing femoral head coverage, stability is improved
and abnormally high loads across the hip joint are reduced. Several studies have reported good medium- tolong-term hip joint survivorship and functional outcome(9, 12, 13, 16, 17, 19-22).

Increasingly, recent reports have focused on survival andfunction of the joint, with few studies describing healthrelated quality of life (HRQoL) and other activities of dailyliving (16, 20, 21). Patients are often young and have highdemands and expectations of the function of their hip,both in everyday life, during recreational activities, and atwork. These other aspects should be considered whenevaluating the outcome of PAO and should be reported at
medium- to long-term follow-up.
Due to the lack of focus in contemporary literature on alternative, yet very important, aspects of outcome measurement, our aims were to explore other functional and qualityof life aspects after PAO surgery. We aimed to answer thefollowing questions: 1) does PAO affect the patient’s sexlife; 2) does PAO affect the patient’s ability to participate in© 2013 Wichtig Editore - ISSN 1120-7000

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Abilities in sports, social activities and sexual life after PAOsports; 3) does PAO affect the patient’s ability to interact
socially; and 4) are the patients satisfied with the outcomeof the procedure at medium to long-term follow-up?

MATERIAL AND METHODS
The study is a retrospective cohort, cross-sectional review
of preserved hip joints a minimum of nine years following PAO surgery. Hospital records identified 100 patients(121 PAOs) operated by KS from December 1998 throughDecember 2002. The medium-term outcome for thiscohort has previously been reported (16). Indications for
PAO were, symptomatic acetabular dysplasia of the hip
defined by persistent pain in the hip or groin, a Wiberg(23) centre-edge angle <25°, a congruent hip-joint, flexionof the hip >110°, and internal rotation >15°. All surgery
utilised an ilioinguinal approach (16).
Five of the 121 PAOs were performed in four foreign citizens and were thus lost to follow-up. At review an inquiry
to the National Patient Registry identified 36 PAO procedures (in 35 patients) had been converted to THA. The
61 remaining patients (80 preserved hip joints) were asked
to participate in a questionnaire-based follow-up. Fifty-fivepatients (70 preserved hip joints) accepted and constituted the study population. A questionnaire concerning
aspects of functional ability, patient satisfaction, expectations, and quality of life following PAO was developed, andvalidated by the authors. Fifty-two patients (68 preservedhip-joints) returned the questionnaire (response rate: 85%),
77% females. Thirty-six patients had been operated with
PAO unilaterally and sixteen bilaterally. Mean age at surgery was 31 years (range 14-56) and at follow-up 41 years(range 24-67). Mean follow up was ten years (range 9-12).
Mean preoperative CE-angle was 12° (range -29°-30°) andpostoperatively 29° (range 4°-52°). Preoperatively all hips
had a Tönnis grade 0-1 and at follow-up 83% had a Tönnis
grade 0-1. One author (AT), blinded as to the status of thehip, assessed all radiographs.

Development of the questionnaire
No existing questionnaires met our requirements andtherefore we developed our own questionnaire. A semistructured interview was conducted including 20 membersof the staff comparable to PAO patients with respect toage and gender. After corrections a new semi-structured
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interview was conducted including 20 patients in the Orthopaedic Department at the Copenhagen University Hospital,Hvidovre, Denmark. The last round of interviews revealed
no need for changes. This validation process, validated
the content by face validity. The questionnaire consist of
11 items concerning the status at follow-up: 1) satisfaction
with the outcome of PAO; 2) quality of life; 3) social ability;4) daily activity; 5) work-life; 6) sexual life; 7) sports activity;
8) pain; 9) limp; 10) stability of the hip; and 11) willingness
to repeat PAO surgery. Items 2) to 10) consisted of threequestions: 1) preoperative status; 2) status at follow-up;3) satisfaction with their current status. Answers were given on five-point or six-point Likert scales with 1 being theworst status and 5 or 6, respectively, the best status.

Statistical analysis
Descriptive statistics were performed and data primarily
presented as prevalences. The Wilcoxon Signed Rank
test for paired data was used to compare preoperativeand postoperative data. A p-value <0.05 was considered
statistically significant. Data were analysed using SPSS
20.0 (IBM, Chicago, Illinois, USA.).

RESULTSMedian overall satisfaction with the outcome of treatment was 5 at follow-up (range 1-5). At follow-up 44 of 49
patients were willing to undergo treatment again with theexperience and knowledge they have today (three patients returned invalid answers). Improvements were seenin all quality of life parameters; quality of life, ability to dosports, ability to participate in social activities and sex-life(p values <0.001), (except for ability in sex-life for males,p = 0.102) (Tab. I). The median pain score before PAO was
2.0 and 4.0 at follow-up (p<0.001). The median limp score
was 2.0 before PAO and 4.0 at follow-up, indicating statistically significantly less limping (p<0.001). The medianstability score was 3.0 before PAO and 4.0 at follow-up,indicating a reduced feeling of hip instability (p<0.001).

DISCUSSION
Valenzuela et al reported that 25%-40% of female patients
experienced positive changes in their sex-life after PAO (21).

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Klit et al

TABLE I - PRE- AND POSTOPERATIVE SCORES, P-VALUES AND SATISFACTION FOR QUALITY OF LIFE, FOUR ALTERNATIVEFUNCTIONAL OUTCOMES AND THREE TRADITIONAL FUNCTIONAL OUTCOMES
Score

Preop. status

Postop. status

P-valueMedian (range)
satisfaction with theresult at follow-up*

Quality of life Medianscore (range)

1 = extreme disabled
2 = disabled in some degree3 = moderately disabled
4 = almost not disabled
5 = not disabled

2.0 (Range: 1-5)

4.0 (Range: 1-5)

P<0.001

4.0 (Range: 1-5)

Ability to do sports

1 = always disabled by my hip
2 = nearly always disabled by my hip
3 = sometimes disabled by my hip
4 = rarely disabled by my hip
5 = never disabled by my hip

2.0 (Range: 1-5)

3.0 (Range: 1-5)

P<0.001

4.0 (Range: 1-5)

Ability to participate
in social activities

Same score as above

3.0 (Range: 1-5)

4.0 (Range: 1-5)P<0.001

4.0 (Range: 1-5)

Ability in sexlife female

0 = no sex-life due to otherreasons than the hip**
1 = no sex-life due to my hip
2 = always disabled by my hip
3 = nearly always disabled by my hip
4 = sometimes disabled by my hip
5 = rarely disabled by my hip
6 = never disabled by my hip

4.0 (Range: 1-6)

5.0 (Range: 2-6)

P = 0.008

4.0 (Range: 1-5)

Ability in sex-life male Same score as above

5.5 (Range: 3-6)

6.0 (Range: 5-6)

P = 0.102

5.0 (Range: 4-5)Pain

1 = pain that disturbed the sleep
2 = pain when in rest
3 = pain under physical activity
4 = pain under hard physical activity
5 = never pain

2.0 (Range: 1-5)

4.0 (Range: 1-5)

P<0.001

4.0 (Range: 1-5)Limp

1 = always limp
2 = limped after a few
hundred metres
3 = limped after 1 kilometre
4 = limped after 3 kilometre
5 = never limp

2.0 (Range: 1-5)

4.0 (Range: 1-5)

P<0.001

4.0 (Range: 1-5)

Stability

1 = never stable
2 = sometimes unstable at rest
3 = unstable under physical activity
4 = unstable under hard
physical activity
5 = never unstable

3.0 (Range: 1-5)

4.0 (Range: 1-5)

P<0.001

4.0 (Range: 1-5)

*1 = not at all satisfied; 2 = very little satisfied; 3 = satisfied in some degree; 4 = mostly satisfied; 5 = fully satisfied.
**not included in statistics.

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Abilities in sports, social activities and sexual life after PAO

Our results showed improvements in the sex-life of bothfemales and males lasting nine to 12 years after PAO surgery. However, only the improvements observed in females
were statistically significant as the improvements in males
failed to show statistical significance (p = 0.102). The abilityof males in sexual performance following PAO has not previously been reported. Van Bergayk et al reported improvements in participation in sports at short term follow-up after
PAO surgery (20). We found a significant improvement in
the ability to do sports at long-term follow-up. A generaldecrease in the ability to do sports is expected during a
10 year period and this is probably the reason why the improvement is only marginal. The lasting improvements after
PAO observed with respect to pain reduction, increased hipstability, and reduction of limping supports that patientswould achieve improved abilities to do sports. We founda significant improvement in the patients’ ability to interact
in a social context (meeting friends, going to the movies,concerts, shopping etc.). We acknowledge that our results
may be affected by recall bias (see below), and in additionchanges in lifestyle during the near 10 year follow-up period
may also affect the findings. As in other studies we foundstatistically significant improvements in HRQoL (16, 20, 21),and both satisfaction with the result and willingness to repeat were high indicating lasting success of PAO surgery.
The following limitations to our study should be acknowledged. Firstly, the study cohort as selected only includes
preserved hips. This may bias the outcome to be better
than can be expected in general. Secondly, recall bias isintroduced by the questions regarding the preoperativestatus. This might result in a bigger difference between

the preoperative and postoperative scores than is actually the case. Finally, the used questionnaire was designed
specifically for this study, which could result in generalisability problems. However, this is a general problem whenevaluating the outcome in younger patients following jointpreserving hip surgery. There is a lack of standardised outcome measures that are able differentiate improvementsin these high demand patients. When using standardised
patient reported outcome measures developed for osteoarthritic hips, this group will show a ceiling-effect.
In conclusion, our results suggest that it is possible toachieve lasting improvements in the patients’ sex life, social life and ability to do sports nine to 12 years following
PAO. Only few previous reports document the outcomeof these alternative outcome measures. However, given
the high demands to the performance of the hip joint thatthese young patients have, these outcome measures areimportant to document all aspects of the long-term success of PAO surgery.
Financial Support: None of the authors have financial relationships
with any organisations that might have an interest in the submittedwork.
Conflict of Interest: None of the authors have relationships or activities that could appear to have influenced the submitted work.
Address for correspondence:
Jakob Klit
Copenhagen University Hospital Hvidovre
Kettegaard Allé 30
2650 Hvidovre
Copenhagen, Denmark
j.klit1@gmail.com

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