Sex After Hip Replacement

Most patients are too timid or embarrassed to ask questions regarding “sex after hip replacement” with their orthopaedic surgeon. A published paper in fact reported that 80% of surgeons rarely or never discuss sexual activity with patients, and of those who do, 96% devote extremely little time to the topic.

I also tend not to direct discuss this topic with my patients but I routinely collect detailed quality of life (QOL) information from my patients via a standardised and validated QOL questionnaire that includes questions regarding sexual function and have observed that the majority of patients with severe arthritis report impediments with sexual activity secondary to their arthritis.
It follows, therefore, that the majority of patients who undergo hip replacement are, or would like to be,  sexually active and most likely have unanswered questions regarding resumption of sexual activity after total joint replacement.

There are few published reports the effect of total hip replacement on sexual function and very little advice on when such activity can be safely resumed.
In lieu of absent quality research, I performed a google search on this topic and noticed that some surgeons’ websites mention 6-12 weeks (without much discussion). I feel that this generalisation may be incorrect for many patients and should be clarified/justified.

It is true that many traditional approaches for hip replacement require that the patient follow a long list of postoperative “precautions” or restrictions, designed to protect the surgical repair of tissues cut and then repaired during surgery.

For example, in the lateral approach to the hip a portion of the gluteal tendon (abductor tendon) is cut from the side of the femur and later repaired. Patients are commonly required to utilise a special pillow to keep their legs apart and to avoid adducting (or crossing their legs inward) for several weeks to allow the abductor repair to heal.

In the posterior approach (most commonly performed approach in Australia), the posterior capsule and short external rotators of the hip are cut , the hip dislocated posteriorly during surgery and these structures later repaired. Patients are then usually placed on a range of postoperative restrictions to allow these repairs to time to heal.

For example, when a posterior approach is performed, patients are often advised not to flex their hips beyond 90 degrees, not to squat or sit on low seats, not to cross their legs, and not to bend too far forward. It follows therefore that many sexual positions may place the patient’s hip in a position of risk of dislocation after posterior hip replacement.

However, in the Direct Anterior approach, surgery is performed between muscles at the front of the hip. The abductor muscle is not violated and the posterior capsule and short external rotator muscles are also NOT cut. Patients are therefore usually allowed to lie on their side, cross their legs, flex and bend forward, and sit on low chairs after anterior hip replacement.

The position in which the femur is placed to facilitate surgery via the direct anterior approach (hip extension combined with external rotation of the leg) is not a natural position that a patient is likely to imitate. Therefore, patients typically do not need to be prescribed “precautions” after anterior hip replacement. I personally do not prescribe any restrictions on patients’ range of movement after anterior hip replacement.

The current trend in recovery after joint replacement aims for Early Rehabilitation After Surgery (ERAS) and entails early ambulation, early discharge from hospital and early return to full functional activity.

Although I tend not to routinely discuss sexual activity with patients, I feel that return to sexual activity can occur early after anterior hip replacement. Some surgeons who mainly utilise traditional surgical approaches endorse a limited range of “safe” sexual positions after posterior hip replacement.    I don’t see any logical rationale in restricting patients’ sexual activity for several weeks in any capacity after anterior hip replacement.

It may of course well be that a patient may chose to delay resumption of such activities due to post op discomfort, lethargy, body image or disinterest after having just had major surgery or secondary to medications they may be taking, but after anterior hip replacement patients can be reassured that their hip replacement is stable and that resumption of sexual activity will not endanger their prosthesis.

I intend to follow up with my patients via post op repetition of the quality of life questionnaire and to report and publish on this under-discussed but relevant topic for patients.