Rita Harmsen

Introduction

Osteoarthritis (OA) is a prevalent chronic degenerative disease of the musculoskeletal system, characterized by pain, stiffness, and joint mobility limitation. In the Netherlands, approximately 1.5 million people experience OA to varying degrees, with more women than men affected. Treatment initially focuses on pain reduction and lifestyle adjustments, with surgery such as Total Knee Arthroplasty (TKA) or Total Hip Arthroplasty (THA) considered when conservative measures fail. Symptoms of OA can significantly impact daily activities, including sexual activity. Chronic pain and movement limitations due to OA can affect sexual activity and can cause tension in sexual relationship with the partner, mostly interfering for years until the decision for surgery is made.

This dissertation explores the perspectives of patients and partners regarding sexual activity before and after THA and TKA (Part I). Additionally, practices of orthopaedic surgeons are examined, including the timing and safe resumption of sexual activity after THA and TKA (Part II). The dissertation focused on the concept of “sexual activity” based on the functional aspect of intercourse rather than the broader domain of sexual quality of life.

Twelve common sexual positions known as the “twelve common sexual positions of Dahm” were used to further define sexual activity as functional mobility. We used the same sexual positions (as used in previous literature) as referring chart during the couple’s interviews, and as an attachment next to the questionnaire which we have sent to THA and TKA orthopaedic surgeons (Chapter 5). The referring chart is included in the appendix of this dissertation.

Part I: Perceptions of Patients and Their Partners
A systematic review of literature on sexual activity in THA patients revealed a lack of research (Chapter 2). Articles on sexual topics in patients before or after THA/TKA were extensively searched (January 1970 to February 9, 2015). No literature was found for TKA. Shortly after the search deadline, the first quantitative retrospective article on sexual activity before and after TKA was published. Two years later, a retrospective article with more qualitative descriptions revealed that patients after TKA do experience many problems during sexual activity due to the diminished knee flexion (bending knee). The review included twelve studies, in total 2,099 patients aged 20–85 years. The methodological quality of ten studies was assessed as low, with only two of moderate quality.

The majority of patients experienced an improvement in “sexual quality of life” after surgery, both in terms of physical-functional and psycho-social well-being. However, the improvements varied widely: the change between preoperative and postoperative ranged extensively (sexual dysfunction before surgery Δ 8–51%, and resuming sexual activity after surgery Δ 0–77%).

We noted, the topic of sexual activity after THA and THA is under-researched. Investigating whether THA and TKA patients have expectations regarding sexual activity after surgery and whether those expectations are met, was justified.

Expectations of Sexual Activity in Patients
The Hospital for Special Surgery Expectation Survey (HSS) is a questionnaire used in many countries for this purpose. The questionnaire includes important items about expectations of daily life; the expectation of sexual activity is one of these. The HSS is longitudinally used as part of the Longitudinal Leiden Orthopaedics Outcomes of Osteoarthritis Study (LOAS) data and embedded in the LROI (Dutch Arthroplasty Register). There is a preoperative questionnaire asking patients about their postoperative expectation and a postoperative questionnaire asking about the “current status”. By comparing these, the score and degree to which extent the expectation is fulfilled are determined.

Chapters 3 and 4 examined the expectations of sexual activity after surgery in THA and TKA patients. Two prospective multicentre cohort studies were conducted, analysing outcomes of 972 THA and 866 TKA patients. Both studies further examined associations, comparing the HSS with functional and health related questionnaires, longitudinally administered by LOAS as well.

For THA, 43.5% of patients did not meet the expectation of sexual activity after surgery, and for TKA patients, 42% did not. These outcomes were high compared to existing literature. The differences are likely explained by differences in sample sizes, year of search, and the large number of losses to follow-up, particularly concerning the question about the expectation of sexual activity. For this reason, we had decided to only use data from patients who had completed both the pre- and postoperative question. For both groups, associations with functional recovery and patient health related outcomes were found, which were generally lower in patients who did not meet their expectations. The results of both studies underscored the need for more in depth qualitative research. A semi-structured interview was a fluent next step.

Interviewing Patients’ and Partners’ Perceptions of Activity
Chapter 5, part I describes the themes emerged from the semi-structured interview. This qualitative research was conducted, one and a half year after surgery, with the patient and their partner, and with a senior orthopaedic surgeon as interviewer. Of the 150 invitations (sent by post, with an invitation letter including a clear explanation of the research purpose, and signed by their own practitioner), we received 90 responses. The majority (n = 85) returned the “non-participation” form. Only 5 couples were willing to participate in the interview. Reason for non-participation was mainly due to “not being sexually active” (47%), which was an exclusion criterion for the study, and the remaining 53% were sexually active, though, 60% of all invited couples responded hesitating difficulties in discussing sexual issues. This indicated a significant taboo around this topic.

The small sample of the 5 couples who shared the conversation provided a homogeneous picture. Two themes were emerged: (i) couples adapted physically and mentally to new situations (both pre- and postoperatively) without considering safety of positions; (ii) couples fully trusted the surgeon as provider of information on safe resumption, if indicated. All couples were comfortable discussing sexual activity with their partner, in the presence of an orthopaedic surgeon. The small sample provided a clear picture, as a pilot study of a selective group. Generalization of the findings was not possible, which confirms the need for larger-scale research to better understand the prevalence and impact of sexual issues among the larger population of total hip and knee patients and their partners.

Part II: Perceptions of THA and TKA Surgeons
Discussing sexual activity in the consultation room is uncommon for orthopaedic surgeons; this holds true in most countries, including the Netherlands. In 2004, an initial study was conducted among American orthopaedic surgeons, where questions were asked regarding the safety of specific standard sexual positions and the timing for resuming sexual activity post-THA. In 2011, the question about safe resumption was revisited with orthopaedic surgeons in England. In 2016, we surveyed Dutch orthopaedic surgeons on this question — see Table 1.

In this comprehensive survey we further presented several themes to respondents (residents, orthopaedic surgeons, and senior/retired orthopaedic surgeons) in the Netherlands, about issues of sexual activity in THA patients (Chapter 6). The majority (78%) of the cohort reported (almost) never discussing sexual activity with patients during consultations (2016). The primary reason was that patients did not ask questions (47%), which meant that orthopaedic surgeons were unaware of potential patient inquiries (38.6%). This topic was also discussed less frequently with older patients over the age of sixty (25.9%). The “positive impact of a THA on sexual activity” was rated highest by older (retired) surgeons, with male surgeons scoring it higher than female surgeons. The importance of “sexual issues in the decision to undergo surgery” received the lowest ratings from residents. The “estimated risk of dislocation” varied between job roles and genders: female surgeons rated this concern highest (median score 5). More than half (54.1%) indicated that it is the orthopaedic surgeon’s responsibility to provide information on safely resuming sexual activity. Opinions varied on the timing of resuming and were unrelated to the surgical approach.

Table 1: Surgeons’ Recommendations About the Appropriate Timing to Resume Sexual Activity After THA
Waiting time to resume sexual activity after THA:

- Netherlands Orthopaedic Association: Hip Working Group (n = 525; Harmsen et al., 2016): Immediately when the patient feels ready: 174 (33.1%); After 2–4 weeks: 28 (5.3%); After 6–8 weeks: 223 (42.4%); After 3 months: 95 (18.1%); After 6 months: 5 (1%).
- British Hip Society United Kingdom (n = 79; Wall et al., 2011): Immediately when the patient feels ready: 16 (19%); After 2–4 weeks: 39 (47%); After 6–8 weeks: 21 (25%); After 3 months: 3 (4%).
- American Association of Hip and Knee Surgeons USA (n = 251; Dahm et al., 2004): Immediately when the patient feels ready: 10 (4%); After 2–4 weeks: 67 (27%); After 6–8 weeks: 167 (67%); After 3 months: 7 (3%).

Safely Resuming Intercourse Hip and Knee Arthroplasty
In 2023 we published a mixed method study in which results from a semi-structured interview with couples are described and the surgeons’ recommendations on safe resuming of sexual activity after THA and TKA (Chapter 5). The latter were all orthopaedic surgeons and members of the Dutch Orthopaedic Association (specifically the Hip and Knee working groups). We asked surgeons for their opinions on 12 sexual positions (previously used by Dahm et al.) and provided recommendations based on findings from Charbonnier et al., who identified (un)safe positions for men and women in THA patients (based on the same 12 sexual positions).

We found no consensus among THA surgeons, with opinions differing regardless of the surgical approach (Chapter 5, Table 3). Consequently, no standardised information for patients or for Dutch orthopaedic practice was identified. For TKA patients, nearly all orthopaedic surgeons (95%) agreed that virtually all positions were permissible. However, they presumed that patients might not find all positions equally comfortable, as certain positions require extensive knee bending, which could be limiting in many cases. Five percent cited a possible risk of knee implant dislocation, a point not previously discussed in literature. The findings from this chapter underscores the need for further research and clear tailor-made information for patients since there is no communis opinion.

Implications for Clinical Practice

This dissertation highlights a communication gap between patients and surgeons regarding addressing sexual activity in THA and TKA patients. A second gap was found between the surgeons’ expert opinions on safe sexual intercourse positions and the results in literature. The study by Charbonnier et al. was agreed by 50% of orthopaedic THA surgeons as an objectively measured guideline (analysed by MRI imaging). However, a recent (2023) study showed contradictory results (analysed by CT imaging), using the same sexual positions. Therefore, a standard guideline for clinical practice is not investigated. However, the following findings are still important:

- The discussion about sexual activity should be opened in the consultation room. To start the communication, orthopaedic practices need an effective way to bridge this gap between “hesitant” patient and “unaware” surgeon.
- Regarding making sexual activity discussable, the steps of the PLISSIT model provide insight into the professional boundaries and responsibilities of the surgeon.
- Since not all patients are sexually active, patients should be encouraged to ask questions about sexual issues themselves.
- Making sexual activity discussable requires attention in the training of residents.
- Furthermore, in two out of five cases, preoperative patient expectations regarding sexual activity after THA and TKA were not met. Managing expectations should lead to more realistic expectations and knowledge in patients, about what to realistically expect. It is important to know, that bending and kneeling postoperatively will interfere sexual intercourse.
- To achieve an open communication culture, a culture change in society will also have to be obtained; this will support the challenging task of the orthopaedic surgeon to address sexual issues during the consultation.

Future Perspectives

There is a lack of literature describing sexual activity of patients after THA and TKA, which is also related to the preoperative expectation of the patients. Sexual activity is an important part of the quality of (senior) life of many orthopaedic patients and partners. In general, men and women can remain sexually active into their 80s. However, the sexual status of older patients is often misunderstood and neglected by healthcare professionals because of the sensitivity to discuss this topic, both for patients and surgeons. Consequently, addressing sexual activity issues in orthopaedic practice is far from a common attitude and many patients (and partners) will not feel encouraged to bring up questions on this topic.

Creating a more open and supportive communication environment in clinical practice could facilitate addressing sexual activity, which is essential for better understanding the challenges of couples before and after total hip and knee replacement surgery, which will support better future research as well.

Orthopaedic surgeons are far from an agreement on a recommended postoperative waiting time when resuming safe sexual positions after THA, or TKA. Recommendations on what is safe should be part of the postoperative routine instructions, preventing not only potential adverse events, like hip (and knee) dislocation, but also uneasiness of patients on which activities can be started and when.

The number of arthroplasties is increasing with patients undergoing surgery at both younger and older ages. As a result, more THA and TKA patients will face preoperative sexual limitations due to hip and knee OA. Orthopaedic healthcare is more than just a focus on the musculoskeletal disease or injury as such, but also about added value to the patient and partner.

Part IV