Quality of life, sexual function, and gait disturbances after pelvic fractures: An ambispective cohort study at a level 1 trauma centre

INTRODUCTION

Trauma is a leading cause of mortality and morbidity, especially in people of younger age groups. It has been shown that after major trauma, about 74% of patients show a decrease in Health-related quality of life scores. Women are affected more than men¹ Holtslag et al. reported a reduction in mobility, self-care, and daily activities in 48%, 18% and 55% patients, respectively, after major trauma. While pain and discomfort were reported in 63% patients and anxiety or depression in 28% patients.² Furthermore, trauma is also a major economic burden.³ It increases both direct and indirect costs. In India, Prinja et al reported an average out-of-pocket expenditure of 388 USD within 1 month of trauma and 1046 USD after 12 months of injury.⁴ This is a significant economic burden in India, where the average per capita income is about 2000 USD.⁵ Pelvic fractures (PFs) form a distinctive group of injuries as they affect the physical, social, and economic well-being of the patient. They are associated with a myriad of complications that hamper the effective integration of the patient into a useful, productive life. Pain, infertility, decreased quality of life, and sexual dysfunction are the common complications.^6-10 The association of PFs with other organ injuries also delays rehabilitation. An associated urethral or anorectal injury may predispose a patient to prolonged suprapubic cystostomy or a diversion colostomy. These have a major bearing on the psychological well-being of the patient, as they are associated with significant changes in physical and sexual factors. Further, PFs themselves are a major cause of immobilization, predisposing the patient to deep venous thrombosis or bed sores. The advent of angioembolization in the management of pelvic trauma has been found to be associated with gluteal, thigh paraesthesia, and claudication.The follow-up of PF to look for gait disturbances, infertility, quality of life, gluteal claudication, and sexual dysfunction is of prime importance for an effective recuperation from the brunt of trauma. However, even though PFs have a major impact on overall quality of life, there remains a paucity of studies for assessing the impact of pelvic trauma on quality of life. It is especially important in developing countries, where rehabilitation services are still in their infancy. Hence, keeping these points in mind, we planned a study to assess the quality of life in patients with PFs.

METHODOLOGY

This was an ambispective observational study spanning 5 years from 1^st January 2014 to 31^st December 2018. Retrospective data were collected from a prospectively maintained trauma registry from 1st January 2014 to 31st December 2017, while from 1st January 2018 to 31st December 2018, prospective patients were recruited. All patients with PFs admitted under the Division of Trauma Surgery and Critical Care during the said duration were included in the study. Patients who were less than 18 years of age or had a known bleeding disorder were excluded from the study. Patient’s parameters in the form of epidemiological profile and Quality of life analysis were performed. Assessment of QoL and sexual parameters was done for a single time in a retrospective cohort, while prospective patients were interviewed at 1,3, and 6 months of follow-up. A telephonic or a personal interview was conducted with the patients for the following parameters.

1. Gait-whether able to walk, if able to walk-straight or with limping

2. Infertility:

   • Females: - It was defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse. Since the total follow-up of patients in the prospective group was only 6 months, this parameter was assessed in only the retrospective cohort and in those females who achieved 6 months of follow-up in the prospective cohort.

   • Males: - It was defined by premature ejaculation and/or retrograde ejaculation. Premature ejaculation was defined as ejaculation that occurs prior to or within about one minute of vaginal penetration. Retrograde ejaculation was defined as orgasm without semen.

3. Quality of life (QOL)-Using the World Health Organization (WHO-QOL)-BREF questionnaire.¹¹ It measured four domains of life, viz, physical, psychological, and social domains of life.

4. Gluteal claudication- It was defined as a cramping pain in the gluteal region when a person moves-whether present or absent.

5. Libido-For males-BSFI (Brief sexual function inventory) was used.¹² FSFI (Female Sexual Function Index) is a validated measure of sexual function in females.¹³

RESULTS

A total of 586 patients were admitted under the Division of Trauma Surgery and Critical Care during the duration of the study. Out of 586 patients, 67 patients were excluded as they were either less than 18 years of age or had known bleeding disorders, four patients left against medical advice, and 79 patients died during the course of their hospital stay. Of the remaining 418 patients, 133 patients were available for follow-up study. After exclusion, 54 patients from the retrospective cohort were included, while 79 patients were followed up in the prospective cohort. Of the 133 patients, 106 were males, while 27 were females, with a mean age of 34.02 +/- 10.8 years. Pain in the pelvi-perineal region radiating to the legs was present in 37/133 (27.8%) patients.

DISCUSSION

PFs pose a major challenge when rehabilitation is considered, as the majority of patients have residual complications in the form of pain, gait disturbances, quality of life, and sexual dysfunction. Quality of life is a domain that is very little studied in these patients. Different questionnaires have been used for measuring QOL. Banierink utilized EuroQoL 5D (EQ-5D), which measures health-related quality of life based on 5 dimensions of health: mobility, self-care, usual health and usual activity, self-discomfort, and anxiety/depression. He enrolled 192 patients and noted substantially lower physical functioning and QOL after 4 years of follow-up when compared with the general population.¹⁴ Harvey Kelly et al, using Euro QOL, showed quality of life to be lower after pelvic fracture in 77.5% of the study population.¹⁰ Holstein found higher age, complex trauma, and surgery to be associated with poor quality of life after pelvic trauma.¹⁵ In the present study, we utilized the WHO-BREF score. The WHOBREFQOL questionnaire is an internationally validated set to measure the quality of life in the general population in 4 domains: Physical, Psychological, Social, and Environmental. It has been demonstrated to be useful in traumatic brain and spinal cord injury.^16,17 However, to the best of our knowledge, the quality of life using WHO-BREF in pelvic trauma has not been measured before. A comparison with the general population showed a decreased overall QOL in all types of pelvic fracture and in all age groups in all domains of life. However, there was subsequent improvement in all 4 domains at 3 and 6 months follow-up. This indicates that patients with PFs require optimum rehabilitation measures, which, if provided, can improve the QOL in these patients.

Sen et al. reported on 40 patients with pelvic and acetabular fractures and found that pain and limping occurred in 40% of cases during routine follow-up.¹⁸ Chronic post-traumatic pelvic pain has a prevalence of 64% which persisted even after 4 years of injury, and it negatively impacts quality of life issues.⁶ Moreover, the pain increased from the stable to the unstable group. Pain was present in of the patients. In the present study, 31.8% turned up for follow-up, and limping was noted in 25 (31.6%) patients, which improved to only 9 (13%) patients at the 6th month of follow-up. In retrospective patients, it was present in 11(20.4%).

Bratby et al showed that Buttock and/or thigh claudication occurred in 12 patients (31%) after internal iliac artery angioembolization and persisted beyond 1 year in 3 patients (9%).¹⁹ In our study, only four patients (1 retrospective and three prospective) developed gluteal claudication after Bilateral internal iliac ligation or angioembolization. However, since most of the other patients who underwent Bilateral internal iliac artery ligation or angioembolization in the retrospective group did not turn up for follow-up, a definitive statement cannot be made on the incidence of gluteal claudication.

Another important factor that is affected in PFs is sexual function and fertility.Hsu et al, in a case-control study in patients undergoing pelvic angiographic embolization, found an incidence of infertility in the case cohort as 30.7 times higher than in controls.²⁰ In our study, 4/13 patients developed infertility, out of which one had undergone internal iliac artery angioembolization. The present study showed male premature/retrograde ejaculation in 34(36.55%) patients, with an association of urogenital injuries in 15(44%). Five males had undergone bilateral internal iliac ligation or angioembolization. Schenfeld et al showed erectile dysfunction in 72% patients after posterior urethral injury.²¹ Gossous et al showed that angioembolization has no added sexual dysfunction over and above those sexual dysfunctions secondary to pelvic fracture.²²

Ismail et al found urogenital injuries to be associated with sexual dysfunction (p=0.005).²³ Ozumba et al from 1996-1998 on a retrospective study on 41 patients showed a mean BSFI of 25.²⁴ Our study showed a mean BSFI score of 27.61, in the retrospective population followed up after 2-4 years of follow-up. Whereas, a prospective group of 54 patients at 6 months of follow-up had a mean BSFI score of 30.83. Moreover, there was a slight change in the BSFI score at 6 months follow-up (from 26.45 to 30.83). Most of the previous studies used IIEF (International Index of erectile dysfunction) and showed an overall decrease in sexual function after pelvic fracture.⁹ Harvey Kelly et al did a prospective study on 80 cases and showed a mean FSFI score of 24.7.¹⁰ Goussous et al did a retrospective study from 1996-1999 on a group of 37 patients and showed a mean FSFI score of 13.9 with a decrease in all domains(more in arousal, lubrication, and pain).²² The present study on a retrospective population of 13 females showed a FSFI score of 22.97, whereas the prospective study on 14 patients showed a FSFI score of 14.23 after 6 months of follow-up. Moreover, there was a slight change in the FSFI score at 6 months follow-up (from 11.47 to 14.23). This shows the improvement of sexual function in females after pelvic trauma.

LIMITATIONS

The present study had its own limitations. The major limitation was that the majority of the patients from the retrospective cohort did not turn up for the study. Also, we compared the groups' outcomes at 1st, 3rd, and 6th months. A comparison of outcomes in the beginning with outcomes more than a year later could have given more insight into the long-term pattern of complications.

CONCLUSION

To conclude, PFs remain a challenge to the surgeons and to the patients due to the associated long-term morbidity and mortality. As such, there is a need to develop a structured rehabilitation program for patients with PFs. A higher number of detailed studies is required to assess each component of QoL in these patients so that a proper rehabilitation program incorporating economic, social, physical, mental, and sexual needs can be made.