Orthopedics

Feature Article Supplemental Data

Improved Sexual Function After Total Hip and Knee Arthroplasty for Osteoarthritis

Jose A. Rodriguez, MD; Sarah J. Hobart, MD; Ajit J. Deshmukh, MD; Luke G. Menken, DO; Amar S. Ranawat, MD; Parthiv A. Rathod, MD

Abstract

Osteoarthritis of the hip and knee is known to affect sexual activity. For patients with osteoarthritis, pain during sexual activity can lead to decreased quality of life and other associated health issues. The authors designed a prospective study to evaluate the effect of total hip arthroplasty and total knee arthroplasty on the psychosocial and physical aspects of sexuality pre- and postoperatively. Between April 2009 and December 2011, patients received questionnaires in the mail preoperatively. They were asked to return the pre-operative questionnaire before surgery and the postoperative questionnaire 6 months after surgery. Data were analyzed to evaluate the psychosocial and physical aspects of sexuality and participants' subjective assessment of their appearance. Preoperatively, 91% and 67% of patients reported psychosocial and physical issues, respectively. After the arthroplasty procedure, 84% (P<.001) and 47% (P<.001) of patients reported improvement psychosocially and physically, respectively. Of the patients, 16% reported that arthroplasty adversely affected sexual function, with their predominant fear being joint damage (63%). A greater number of women and patients undergoing hip procedures reported improvement in sexual activity after surgery compared with men (P=.02) and patients undergoing knee procedures (P=.002). Both hip and knee osteoarthritis and arthroplasty had a significant effect on overall sexual function—psychosocially, physically, and in terms of patients' assessment of their external appearance—with higher rates of improvement seen after hip arthroplasty. Because of the effect of osteoarthritis and arthroplasty on sexual function, this topic should be addressed both pre- and postoperatively. [Orthopedics. 2021;44(x):xx–xx.]

Abstract

Osteoarthritis of the hip and knee is known to affect sexual activity. For patients with osteoarthritis, pain during sexual activity can lead to decreased quality of life and other associated health issues. The authors designed a prospective study to evaluate the effect of total hip arthroplasty and total knee arthroplasty on the psychosocial and physical aspects of sexuality pre- and postoperatively. Between April 2009 and December 2011, patients received questionnaires in the mail preoperatively. They were asked to return the pre-operative questionnaire before surgery and the postoperative questionnaire 6 months after surgery. Data were analyzed to evaluate the psychosocial and physical aspects of sexuality and participants' subjective assessment of their appearance. Preoperatively, 91% and 67% of patients reported psychosocial and physical issues, respectively. After the arthroplasty procedure, 84% (P<.001) and 47% (P<.001) of patients reported improvement psychosocially and physically, respectively. Of the patients, 16% reported that arthroplasty adversely affected sexual function, with their predominant fear being joint damage (63%). A greater number of women and patients undergoing hip procedures reported improvement in sexual activity after surgery compared with men (P=.02) and patients undergoing knee procedures (P=.002). Both hip and knee osteoarthritis and arthroplasty had a significant effect on overall sexual function—psychosocially, physically, and in terms of patients' assessment of their external appearance—with higher rates of improvement seen after hip arthroplasty. Because of the effect of osteoarthritis and arthroplasty on sexual function, this topic should be addressed both pre- and postoperatively. [Orthopedics. 2021;44(x):xx–xx.]

Human sexuality is the complex expression and experience of individuals and their intimacy with others. Population studies have shown a relationship between sexual function and quality of life.1 Sexual activity has a positive correlation with health, especially in the elderly.2,3 Because of the older age range of patients with osteoarthritis, there are significant ramifications for addressing this population.

The effect of hip and knee osteoarthritis on sexual function has been underacknowledged.4–10 Pain and depression can affect sexual desire and satisfaction, and physical disability can lead to sexual difficulty.11 People experiencing sexual difficulty can struggle with their physical and emotional status, which is associated with depression, perpetuating an unhealthy cycle.1,12

Several studies have shown the effect of hip and knee osteoarthritis on sexuality;5,8,10,13,14 however, often there is inadequate discussion between physicians and patients regarding possible changes in sexual activity.6,14 In a 2004 survey of hip surgeons by Dahm et al,6 80% reported rarely or never discussing sexual activity with patients undergoing hip arthroplasty. In a study of patients undergoing total hip arthroplasty (THA), Wall et al14 reported that 55% of patients would have preferred to receive more information on the effect of arthroplasty on sexual activity. A significant number of patients reported undergoing THA with the expectation that their sexual function would improve.8,15,16 Exacerbating the problem, functional evaluation scores of patients undergoing hip arthroplasty do not assess sexual activity, thus underestimating the difficulty that patients face.16 The unique sexual issues of this patient population are rarely fully evaluated or discussed, making the problem difficult to address.

Most studies of sexuality among patients undergoing hip and knee arthroplasty are retrospective, and few of the limited number of prospective studies have included patients undergoing knee arthroplasty. To the best of the authors' knowledge, 2 studies have evaluated the effect of total knee arthroplasty (TKA) on sexual function among patients with knee osteoarthritis.17,18 The goals of the current study were to (1) evaluate the effect of hip and knee osteoarthritis on the psychosocial and physical aspects of sexuality and patients' subjective assessment of their overall external appearance and report the effect of THA and TKA on these metrics; (2) identify factors associated with restriction of sexual activity after THA and TKA; and (3) identify differences in sexual activity related to age, sex, and joint involved (hip vs knee).

Materials and Methods

A prospective study of patients undergoing primary hip and knee arthroplasty performed by 2 high-volume arthroplasty surgeons (J.A.R., A.S.R.) at a single center was undertaken. The authors selected study participants from a consecutive cohort of patients undergoing surgery between April 2009 and December 2011. Inclusion criteria were a diagnosis of osteoarthritis, age 18 to 70 years, and planned primary uni-lateral or bilateral THA or TKA. Exclusion criteria included American Society of Anesthesiologists grade III or higher, a psychiatric disorder, and primary or secondary genital tract disease or abnormality. The study protocol was reviewed by the institutional review board, which recommended exemption from institutional review board monitoring because the study used an anonymous questionnaire.

Potential study participants were mailed questionnaires about sexuality for completion preoperatively (Figure A, available in the online version of the article) and 6 months postoperatively (Figure B, available in the online version of the article). They were also sent a declination letter to complete if they did not wish to participate. The authors mailed patients a second postoperative questionnaire if they did not return the first postoperative questionnaire at 6 months (Figure C, available in the online version of the article). Patients who returned postoperative questionnaires were included in the postoperative cohort. A unique code was assigned to each patient to maintain anonymity, and no other patient identifiers were included on the mailed forms.

Preoperative questionnaire.

Figure A.

Preoperative questionnaire.

Questionnaire 6 months after surgery.Questionnaire 6 months after surgery.

Figure B.

Questionnaire 6 months after surgery.

Questionnaire 1 year after surgery.

Figure C.

Questionnaire 1 year after surgery.

The authors developed the sexuality questionnaire after incorporating some of the elements discussed in previously published literature.5,7,19 Some questions were added based on the authors' clinical experience with patients' questions, expectations, and the overall goals of the study. The authors characterized sexuality in this study with 3 main components: psychosocial, physical, and self-perceived external appearance. The psychosocial component included general well-being, self-esteem, sexual self-image, and ability to perform spousal duties (ie, employment, housework, errands, caring for children/ grandchildren). The physical component included any change in the frequency and duration of sexual activity as well as the occurrence of orgasm. The questionnaires focused on perceived causes of sexual dysfunction and the location and characteristics of pain during intercourse. Finally, the patients were asked to assess their physical appearance (weight, muscle tone, appearance of the affected joint, posture, walking pattern). The preoperative and postoperative questionnaires included similar questions to ensure consistency for comparison. Responses were provided in a yes/no format.

All THA procedures used cementless components, with either the posterior or the direct anterior approach. All TKA procedures used the medial parapatellar approach and posterior-stabilized cemented implants. The multimodal pain management protocol was similar for all THA and TKA procedures. Patients started physical therapy on postoperative day 1 and continued therapy on discharge. They were advised to resume activities as they could tolerate, with comfort being their guide. Both surgeons allowed resumption of sexual activity 6 weeks after surgery. A standardized booklet with information on sexual activity after surgery was provided to patients on request.

Statistical analysis was performed with SPSS, version 16, software (SPSS, Inc). Data were described as the percentage of patients who responded to a particular question. For preoperative questions, the denominator was the total number of patients in the preoperative cohort, and for postoperative questions, the denominator was the total number of patients in the postoperative cohort. Data were analyzed for differences in frequency of sexual activity among the demographic groups (joint, sex, age) both pre- and postoperatively. Similarly, differences were analyzed for frequency of sexual activity between the pre- and postoperative groups. Categorical variables were analyzed with a chi-square test with Fisher's exact test. Statistical significance was set at P=.05.

Results

A total of 463 consecutive patients were mailed the preoperative forms between April 2009 and December 2011. Of these, 32% (147) returned the preoperative questionnaire and formed the preoperative cohort. Of the initial group, 25% of patients (116) returned the postoperative questionnaire. In addition, 20% of patients (91) actively declined to participate in the study by returning the declination letter. The authors did not receive a response from 48% of patients (225). Demographic features are shown in Table 1.

Demographic Features

Table 1:

Demographic Features

In the preoperative cohort (Figure 1A), 91% of patients (134 of 147) reported that osteoarthritis affected their general well-being and 78% (115) reported that the ability to perform spousal duties was significantly affected. Slightly more than half of the cohort reported that self-esteem (56%) and sexual self-image (53%) were affected by osteoarthritis. Postoperatively (Figure 1B), a significant number of patients reported that surgery had a positive effect on these parameters, with 84% (123) reporting improved general well-being (P<.001), 72% (106) reporting improved ability to perform spousal duties (P<.001), 68% (100) reporting improved self-esteem (P<.001), and 55% (81, P=.21) reporting improved sexual self-image. Preoperatively, 66% (97 of 147) of the cohort reported that their sexual activity had decreased as a result of osteoarthritis (Figure 2A). Of the participants, 66% (97) reported a decrease in the frequency of sexual intercourse, 56% (82) reported decreased duration of sexual intercourse, 40% (59) reported a decrease in the occurrence of orgasm, and 49% (72) reported a decrease in sexual desire or libido. Postoperatively (Figure 2B), 47% (54 of 116) patients reported improvement in the frequency of sexual intercourse, 36% (41) reported improvement in duration of sexual intercourse, 28% (33) reported increased occurrence of orgasm, and 42% (49) reported increased libido. A statistically significant decline was seen in the number of patients reporting decreased duration of sexual intercourse (P<.001), decreased rate of occurrence of orgasm (P<.001), and decreased sexual desire (P<.001) postoperatively compared with preoperatively.

Graphs showing patient responses to the psychosocial portion of the questionnaire, including the psychosocial aspects of osteoarthritis (A) and improvement in psychosocial components after arthroplasty (B).

Figure 1:

Graphs showing patient responses to the psychosocial portion of the questionnaire, including the psychosocial aspects of osteoarthritis (A) and improvement in psychosocial components after arthroplasty (B).

Graphs showing patient responses to the physical portion of the questionnaire, including the physical sexual aspects of osteoarthritis (A) and changes in physical components after arthroplasty (B).

Figure 2:

Graphs showing patient responses to the physical portion of the questionnaire, including the physical sexual aspects of osteoarthritis (A) and changes in physical components after arthroplasty (B).

In addition, 89% (130 of 147) of patients reported that osteoarthritis negatively affected their overall appearance preoperatively (Table 2). Postoperatively, patients reported a noticeable improvement in their self-perceived image. This difference included improved walking pattern (72%, 83 of 116), improved posture (44%, 51), improved joint appearance (39%, 45), weight loss (23%, 27), and improved muscle tone (11%, 13).

Patients' Subjective Assessment of Overall Appearance

Table 2:

Patients' Subjective Assessment of Overall Appearance

The most common causes cited for a decline in sexual activity preoperatively were pain or stiffness at the affected joint (pain, 67%; stiffness, 36%), loss of sexual desire (19%), difficulty attaining an appropriate position (14%), and overall fatigue (7%). During sexual activity, patients who had hip osteoarthritis experienced pain in the groin and lateral hip region (91%), whereas patients who had knee osteoarthritis had medial (36%) and anterior (48%) knee pain. In the postsurgical cohort, a statistically significant decrease was seen in the number of patients whose sexual activity was negatively affected compared with before surgery (16%, 19) (P<.001). The principal reason cited for a decline in sexual activity after surgery was fear of damaging the replaced joint (63%, 12 of 19). Other causes included pain or discomfort of the affected joint during sexual activity (32%, 6) and inability to attain an appropriate position of the affected joint (26%, 5).

Preoperatively, sexual activity was more significantly affected in patients undergoing THA compared with TKA (73% vs 53%, respectively; P=.02) (Table 3). Similarly, a higher proportion of patients undergoing THA (57%) reported improvement in the frequency of sexual activity compared with those undergoing TKA (27%, P=.002). More women than men were affected preoperatively (P=.01), and women noted greater improvement after surgery as well (P=.02) (Table 4). Further analysis showed that this difference was mainly noted for patients undergoing THA (P=.02 hip vs P=.9 knee).

Differences in Sexual Activity Between Patients Undergoing Hip and Knee Surgery in the Preoperative and Postoperative Cohorts

Table 3:

Differences in Sexual Activity Between Patients Undergoing Hip and Knee Surgery in the Preoperative and Postoperative Cohorts

Differences in Reported Sexual Activity Between Men and Women in the Preoperative and Postoperative Cohorts

Table 4:

Differences in Reported Sexual Activity Between Men and Women in the Preoperative and Postoperative Cohorts

Discussion

Chronic hip and knee osteoarthritis has a significant effect on quality of life. Hip and knee arthroplasty improves not only joint pain but also well-being and mental perspective. This study highlighted the important relationships among hip and knee osteoarthritis, arthroplasty, and sexuality. Of the participants, two-thirds (66%) reported that their sexual activity had decreased before surgery, and 56% (54 of 97) of those affected reported subsequent improvement.

This study showed that osteoarthritis affects sexuality not only physically but also mentally. The ability to perform spousal duties can affect sexuality indirectly because of strain on the relationship. Currey5 found that 23% of patients with hip osteoarthritis reported unhappiness or tension in their marital relationship as a result of sexual difficulty. A healthy self-appraisal and the ability to perform spousal duties have the potential to increase harmony in relationships. Of the patients, 16% noted a decline in the frequency of sexual activity after surgery, which is consistent with reports in the literature of 1% to 27% describing a similar decline.7,8,10,18 In the current study, the most common reason for decreased frequency of sexual activity was fear of damaging the replaced joint, followed by pain and stiffness. At the authors' center, booklets on sexual activity were provided to patients who specifically asked for this information. Unfortunately, many patients do not feel uncomfortable discussing this topic. The authors currently tell all patients that most physical activity, including intimacy, is safe as soon as they feel comfortable with it.

Many authors have alluded to the lack of information and open communication about sexuality for patients with osteo-arthritis and arthroplasty.6–8,14,19,20 In a survey of members of the American Association of Hip and Knee Surgeons by Dahm et al,6 of the 254 respondents, 80% reported rarely or never discussing sexual activity with patients undergoing THA. Of surgeons who had a discussion with patients, 96% spent 5 minutes or less on this topic. Studies cite that 64% to 89% of patients who have undergone THA prefer to receive more information about safe positions and appropriate timing for return to sexual activity.5,8,10,14 Most patients favor a booklet to dispense the information; however, for those who prefer to have a conversation, the surgeon is the preferred provider.

Preoperatively, 46% to 82% of study subjects reported sexual difficulty as a result of hip pain,5,7,8,10,13–15 which is consistent with the 73% reported in the current study. Pain, stiffness, and fatigue were the main causes of difficulty, which is also concordant with previous research.5,7,8,10,14 In addition to the decrease in frequency of sexual activity, patients experienced both decreased duration of sexual activity and decreased occurrence of orgasm. Preoperatively, 49% of patients reported loss of libido, which can play a detrimental role in a relationship.5,7,10

Several studies have reported that THA leads to a significant increase in the number of patients reporting improved sexual activity after surgery.7,8,14 A retrospective study by Laffosse et al7 showed that only 51% of patients reported no to minimal difficulty with sexual activity preoperatively, a finding that improved to 74% postoperatively. Notably, in their preoperative cohort, women were more likely to report sexual difficulty (P=.04). When this impairment was correlated postoperatively, women showed a significantly greater increase in coital frequency compared with men (P=.02). The current hip cohort paralleled those results, with a significant difference between men and women in sexual activity both before and after surgery and a greater proportion of women showing adverse effects preoperatively (P=.01) and improvement postoperatively (P=.02). Charbonnier et al20 used motion capture analysis to document range of motion of the hip in various sexual positions for heterosexual men and women. They noted that female sexual positions require extreme hip range of motion, notably, high flexion combined with abduction and mostly external rotation, whereas male sexual positions require less mobility. After THA, improvement in the ability to achieve this range of motion without pain is the most likely explanation for the differential improvement in sexual function among women.20 No difference based on sex was found in the TKA group.

Additional comments made by patients highlight some unique perspectives and suggest future areas of exploration in evaluating and judging the success of THA and TKA. Some patients reported that they felt psychosocially younger after surgery and had more energy for various activities. Others reported improvement in their relationship with their partner as a result of improvement in their sexuality. Some patients reported that the questionnaires did not adequately represent the sexuality of homosexual participants. In addition, sexual gratification achieved from self-stimulation was not discussed. These are relevant topics that should be addressed in future studies.

Limitations of this study included a low response rate (52%, including active declinations), although the rate was similar to those of previous studies on this topic, ranging from 33% to 86%.5,7,8,15,19,21 Some patients declined to participants because they believed that they were not young enough to be sexually active, whereas others responded that they were not sexually active because of medical comorbidities affecting themselves or their partners. The study did not include the sexual partners of the patients. Therefore, the study did not fully assess the effect of change in sexual function on their relationships. Future studies should involve sexual partners to obtain a comprehensive perspective.

Strengths of the study included its prospective nature, which ensured that the responses were valid and easily comparable with their baseline preoperative function, thus eliminating recall bias. The authors also evaluated the effect of surgery on patients' subjective assessment of their external appearance, weight, posture, muscle tone, and walking pattern, all of which are important elements of sexual self-image. These measures have not been evaluated in previous studies.

Conclusion

This study showed that osteoarthritis of the hip and knee has a significant effect on sexuality. Despite the potential for discomfort during conversation, sexuality should be addressed throughout a patient's pre- and postoperative experience. Both THA and TKA can offer improvement in many facets of human sexuality—psychosocially, physically, and in self-image. Women who have osteoarthritis and undergo THA appear to experience the greatest benefit.

References

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Demographic Features

CharacteristicValue

Preoperative cohortPostoperative cohort
Patients, No.147116
Age, y
  Mean57.756.6
  Range35–7035–70
Sex, No.
  Female7861
  Male6955
Total hip arthroplasty/total knee arthroplasty, No.
  Hip osteoarthritis9678
  Knee osteoarthritis5138
Marital status, No.
  Married10692
  Divorced138
  Single1911
  Separated95

Patients' Subjective Assessment of Overall Appearance

Physical attributeHow was it affected by arthritis?How was it affected by surgery?
Weight49% weight gain23% weight loss
Muscle tone37% muscle tone lost11% muscle tone improved
Posture61% unhappy with posture44% posture improved
Appearance of affected joint51% unhappy with appearance39% appearance improved
Walking pattern89% unhappy with walking pattern72% walking pattern improved

Differences in Sexual Activity Between Patients Undergoing Hip and Knee Surgery in the Preoperative and Postoperative Cohorts

Joint affectedNo.

Preoperative cohort (147 patients): Sexual activity affected?Postoperative cohort (116 patients): Sexual activity improved?


YesNoYesNo change or declined
Hip70264434
Knee27241028
Pa.02<.01

Differences in Reported Sexual Activity Between Men and Women in the Preoperative and Postoperative Cohorts

Sex (joint affected)No.

Preoperative cohort (147 patients): Sexual activity affected?Postoperative cohort (116 patients): Sexual activity improved?


YesNoYesNo change or declined
Men (hips)28181521
Women (hips)4282913
P.01.02
Men (knees)1013413
Women (knees)1711615
P.27.90
Total men38311934
Total women59193528
P.01.04
Authors

The authors are from the Hospital for Special Surgery (JAR, LGM, ASR) and NYU Langone Health (AJD, PAR), New York, New York; and Towson Orthopaedic Associates (SJH), Towson, Maryland.

Drs Rodriguez, Hobart, Deshmukh, Menken, and Rathod have no relevant financial relationships to disclose. Dr Ranawat is a paid consultant for DePuy, Stryker, Arthrex, and ConforMIS.

Correspondence should be addressed to: Luke G. Menken, DO, Hospital for Special Surgery, 535 E 70th St, New York, NY 10021 ( luke.menken@gmail.com).

Received: September 19, 2019
Accepted: March 02, 2020
Posted Online: January 07, 2021

10.3928/01477447-20210104-01

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