Orthopedics

Case Report 

Safe Positioning for Sexual Intercourse After Proximal Femoral Replacement

Cory G. Couch, MD; Richard W. Nicholas, MD; Corey O. Montgomery, MD

Abstract

Hip arthroplasty is a common procedure used for the treatment of fractures and degenerative processes affecting the hip. Proximal femoral replacement is an uncommon type of hip arthroplasty used for reconstruction after extensive bone loss. Proximal femoral replacement is used most commonly after the resection of the proximal femur for malignancies and for extensive bone loss encountered in revision hip arthroplasty and occasionally for extensive bone loss after fractures. The authors present a case of a female patient who sustained a prosthetic dislocation of her proximal femoral replacement during sexual intercourse. Standard hip arthroplasty itself can pose a risk factor for dislocation associated with certain sexual positions. Proximal femoral replacement surgery likely carries an increased risk for dislocation, given the magnitude of soft tissue loss at the time of resection. The authors believe that routine perioperative conversations for sexually active patients with proximal femur replacements should include this potential risk and discuss appropriate positioning to prevent a potential dislocation. [Orthopedics. 2018; 41(2):e292–e294.]

Abstract

Hip arthroplasty is a common procedure used for the treatment of fractures and degenerative processes affecting the hip. Proximal femoral replacement is an uncommon type of hip arthroplasty used for reconstruction after extensive bone loss. Proximal femoral replacement is used most commonly after the resection of the proximal femur for malignancies and for extensive bone loss encountered in revision hip arthroplasty and occasionally for extensive bone loss after fractures. The authors present a case of a female patient who sustained a prosthetic dislocation of her proximal femoral replacement during sexual intercourse. Standard hip arthroplasty itself can pose a risk factor for dislocation associated with certain sexual positions. Proximal femoral replacement surgery likely carries an increased risk for dislocation, given the magnitude of soft tissue loss at the time of resection. The authors believe that routine perioperative conversations for sexually active patients with proximal femur replacements should include this potential risk and discuss appropriate positioning to prevent a potential dislocation. [Orthopedics. 2018; 41(2):e292–e294.]

Hip arthroplasty (HA) is a commonly performed operation for which dislocation is an uncommon complication, usually resulting from impingement, improper implant positioning, or soft tissue deficiency. Several studies of patients with a HA have identified positions during sexual intercourse that increase the risk for dislocations.1–5 Despite the potential importance, this topic is rarely discussed with patients.1,6

Proximal femur replacement (PFR) is an uncommon type of HA, used primarily in oncologic reconstructions. One study involving 996 patients with a PFR found the incidence of hip instability to be 18.5%, postulating that this high rate was related to the degree of soft tissue excision.7 The literature does not address the relationship between sexual positioning and instability following a PFR. The authors describe a case of PFR dislocation occurring during sexual activity. Both institutional review board and patient approval were obtained prior to preparation of this report.

Case Report

A 45-year-old woman presented with a thigh mass and pain for a year. On examination, she had a palpable, firm soft tissue prominence in the right anterior thigh. Magnetic resonance imaging of the femur revealed a large exophytic mass, arising from the proximal femur with an anterior thigh soft tissue mass (Figure 1). Additional imaging revealed no distant disease, and biopsy confirmed a diagnosis of chondrosarcoma.

Preoperative anteroposterior radiograph of the right hip showing a mineralized mass arising from the proximal femur (A). A T1-weighted magnetic resonance imaging axial cross-section of a large exophytic anterior thigh soft tissue mass arising from the proximal femur (B).

Figure 1:

Preoperative anteroposterior radiograph of the right hip showing a mineralized mass arising from the proximal femur (A). A T1-weighted magnetic resonance imaging axial cross-section of a large exophytic anterior thigh soft tissue mass arising from the proximal femur (B).

For treatment, the patient underwent a 22-cm resection of her right proximal femur and reconstruction with a PFR (Figure 2). Because of the size of the extraosseous mass, both anteromedial and lateral approaches were used. Preserved soft tissues were repaired surrounding the PFR. Range of motion evaluation at closure revealed no evidence of instability. Postoperative rehabilitation proceeded without incident. The risks of instability and hip dislocation were discussed during the perioperative consenting process; however, no specific discussion about safe sexual positioning was had with the patient.

Anteroposterior radiographs of the patient's cemented proximal femoral replacement with a concentrically reduced hip (A, B). Lateral radiograph of the residual distal femur with the cemented proximal femoral replacement in place (C).

Figure 2:

Anteroposterior radiographs of the patient's cemented proximal femoral replacement with a concentrically reduced hip (A, B). Lateral radiograph of the residual distal femur with the cemented proximal femoral replacement in place (C).

The patient presented to the emergency department 20 months postoperatively because of acute, severe hip pain (Figure 3). Her hip had dislocated during sexual intercourse, in a position of flexion, internal rotation, and adduction. An open reduction was required, during which it was confirmed that the prosthetic bipolar head had buttoned-holed through the posterior hip capsule. The hip was reduced, and the defect was repaired. Following surgery, she was placed in an abduction brace to wear for 6 weeks. The patient discontinued the brace prematurely and experienced a repeat dislocation (hyperflexing her hip when attempting to stand from a low seated position) requiring open reduction. She was again fitted with an abduction brace and counseled on full-time use. She has had no further dislocations. An extensive discussion was subsequently held with the patient in the perioperative setting pertaining to acceptable sexual positions.

Postoperative anteroposterior radiograph showing prosthetic dislocation.

Figure 3:

Postoperative anteroposterior radiograph showing prosthetic dislocation.

Discussion

Discussions pertaining to a patient's sexual activity, particularly regarding positioning recommendations, may be uncomfortable or awkward for both the patient and the surgeon. However, a brief discussion addressing this topic could potentially prevent a severe complication. Available data for patients with standard HA implants regarding sexual positioning recommend avoiding internal rotation, hyperflexion past 90°, and limb adduction past midline (crossing one's legs).1

Current recommendations, in addition to expert opinion, are based on intraoperative findings, logical reasoning, and biomechanical principles of HA. One of the few studies using biomechanical evidence evaluated hip joint kinematics during coitus after total HA using magnetic resonance imaging and optical capture of a pair of subjects placed in common sexual positions.5 The most common positions required the woman to have the studied hip in a position of flexion, abduction, and external rotation. For the man, hip flexion and abduction were in the normal range, but external rotation was predominant. The study concluded that the woman's hip positions could result in hip impingement and may lead to dislocation of the prosthesis. The positions with the most risk are those with high hip flexion in combination with wide abduction. The male hip required less mobility throughout the sexual positions and was evaluated to be safer overall. Positions with greater chances for instability that women should avoid include the woman on top of the man and leaning forward, the woman supine with legs apart and knees flexed and the hips of the man under the arch formed by the woman, and the woman on her side lying face to face with the man (Figure 4).5

Safe positions for sex with hip replacement. The bottom position is usually the most comfortable position soon after surgery. The person with the new joint (in gray) is on the bottom. A pillow or two can be placed under the thigh for support. In the side position, both the person with the new joint and the partner are on their sides, one behind the other. The person with the new joint can be in front or in back (both shown in gray) but should not lie on the side with the new joint. In the top position, the person with the new joint (in gray) is on the top. In the sitting position, the person with the new joint (in gray) is on the bottom but should do this only if having the strength to support the partner. (Graphics created by and used with permission of UAMS Center for Health Literacy.)

Figure 4:

Safe positions for sex with hip replacement. The bottom position is usually the most comfortable position soon after surgery. The person with the new joint (in gray) is on the bottom. A pillow or two can be placed under the thigh for support. In the side position, both the person with the new joint and the partner are on their sides, one behind the other. The person with the new joint can be in front or in back (both shown in gray) but should not lie on the side with the new joint. In the top position, the person with the new joint (in gray) is on the top. In the sitting position, the person with the new joint (in gray) is on the bottom but should do this only if having the strength to support the partner. (Graphics created by and used with permission of UAMS Center for Health Literacy.)

Anterior dislocations of the hip are divided into superior and inferior types, account for approximately 10% to 15% of hip dislocations, and were classified by Epstein in his classic study.7,8 Both types occur in an abducted and externally rotated hip position and are uncommon compared with posterior dislocations. Sexual positioning placing the hip in extremes of abduction and external rotation should be avoided.

Other factors can contribute to overall hip stability, such as the surgical approach, the extent of soft tissue and bone resection, and the type of reconstruction. Although the direct anterior approach theoretically results in a lower risk of dislocation compared with a posterior approach, dislocation is still a possibility.5 Bipolar implants are inherently more stable than total arthroplasty, and these implants are often used in oncologic operations, for which soft tissue deficiency is a frequent challenge.9 However, even with the use of a bipolar HA, the potential for instability remains, given the 18.5% instability rate noted by Henderson et al.9 The amount of soft tissue tumor extension for proximal femoral malignancies dictates the amount of soft tissue excision required for these procedures. Soft tissue stabilization after PFR can be problematic even in cases where most of the musculature and capsule can be preserved.

An additional concern regarding potential postoperative management of patients who have had PFR arises because there has been an increase in the use of PFR for non-oncologic conditions such as revision arthroplasty and in traumatic cases. Colman et al10 noted an overall 19% dislocation rate for PFR used in the treatment of acute periprosthetic fractures. A portion of such non-oncologic patients are likely to be sexually active, and appropriate perioperative conversations regarding this risk could potentially prevent unwanted complications such as hip instability and dislocation.

Conclusion

Given the documented rates of potential problems following surgery, the authors believe that positioning during sexual intercourse should be a brief part of every routine perioperative discussion for all patients undergoing HA. This discussion may be particularly important for sexually active patients undergoing a PFR. The authors recommend that patients use caution when engaging in sexual activity, avoiding positions involving internal rotation, hyperflexion, and adduction of the hip as well as other positions that could result in extreme hip positioning.

References

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  2. Stern SH, Fuchs MD, Ganz SB, Classi P, Sculco TP, Salvati EA. Sexual function after total hip arthroplasty. Clin Orthop Relat Res. 1991; 269:228–235.
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  6. Dahm DL, Jacofsky D, Lewallen DG. Surgeons rarely discuss sexual activity with patients after THA: a survey of members of the American Association of Hip and Knee Surgeons. Clin Orthop Relat Res. 2004; 428:237–240. doi:10.1097/01.blo.0000137555.74475.a5 [CrossRef]
  7. Goddard NJ. Classification of traumatic hip dislocation. Clin Orthop Relat Res. 2000; 377:11–14. doi:10.1097/00003086-200008000-00004 [CrossRef]
  8. Epstein HC. Traumatic dislocations of the hip. Clin Orthop Relat Res. 1973; 92:116–142. doi:10.1097/00003086-197305000-00011 [CrossRef]
  9. Henderson ER, Groundland JS, Pala E, et al. Failure mode classification for tumor endoprostheses: retrospective review of five institutions and a literature review. J Bone Joint Surg Am. 2011; 93(5):418–429. doi:10.2106/JBJS.J.00834 [CrossRef]
  10. Colman M, Choi L, Chen A, Crossett L, Tarkin I, McGough R. Proximal femoral replacement in the management of acute periprosthetic fractures of the hip: a competing risks survival analysis. J Arthroplasty. 2014; 29(2):422–427. doi:10.1016/j.arth.2013.06.009 [CrossRef]
Authors

The authors are from the Department of Orthopedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Cory G. Couch, MD, Department of Orthopedic Surgery, University of Arkansas for Medical Sciences, 4301 W Markham, Slot 531, Little Rock, AR 72205 ( cgcouch@uams.edu).

Received: January 25, 2017
Accepted: August 02, 2017
Posted Online: September 22, 2017

10.3928/01477447-20170918-09

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