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Patient Expectations of Sexual Activity After Total Hip Arthroplasty: A Prospective Multicenter Cohort Study

Harmsen, Rita T.E., MHA, MSc1; den Oudsten, Brenda L., PhD2; Putter, Hein, PhD1; Leichtenberg, Claudia S., BSc1; Elzevier, Henk W., MD, PhD1; Nelissen, Rob G.H.H., MD, PhD1 (on behalf of the LOAS Study Group)

doi: 10.2106/JBJS.OA.18.00031
Scientific Articles: PDF Only

Background: This study aimed to evaluate patients’ expectations of postoperative sexual activity (SA) after total hip arthroplasty.

Methods: A prospective multicenter cohort study of 1,271 patients managed with total hip arthroplasty was performed using patient-reported outcome measures of the Longitudinal Leiden Orthopaedics Outcomes of Osteo-Arthritis Study (LOAS). Preoperative SA expectations and their fulfillment after 1 year were assessed with the Hospital for Special Surgery expectations survey. The Hip disability and Osteoarthritis Outcome Score (HOOS) was used to measure functional status, and the Short Form-12 Mental and Physical Component Summary scores (SF-12 MCS and SF-12 PCS) and EuroQol-5 Dimensions (EQ-5D) questionnaire were used to measure health status. Two subgroups were defined preoperatively: the SA-Expecting Group and the No-SA-Expecting Group. The postoperative outcomes with regard to SA (i.e., the difference between postoperative and preoperative SA scores) were classified as “unfulfilled” (score, ≤−1), “fulfilled” (score, 0), or “exceeded” (score, ≥1). Multivariate regression analyses were used, with t tests to compare means between groups.

Results: In total, 952 (74.9%) patients returned both preoperative and postoperative HSS questionnaires. Preoperatively, 605 patients (63.6%) expected to have postoperative SA. At 1 year, 43.5% of participants reported that this expectation was unfulfilled. In the No-SA-Expecting Group, 18.2% (63 of 347) regained SA, predominantly men. Postoperative SA fulfillment was related to preoperative musculoskeletal (p = 0.001) and non-musculoskeletal comorbidities (p = 0.004) and the postoperative HOOS, SF-12 PCS, SF-12 MCS, EQ-5D, and EQ-5D visual analog scale (VAS) scores (p < 0.001). Postoperative HOOS-symptoms (odds ratio [OR] 1.04; 95% confidence interval [CI], 1.02 to 1.06; p < 0.001), and HOOS-sport (OR, 1.01; 95% CI, 1.00 to 1.03; p = 0.032) were associated with postoperative SA fulfillment, as was older age (inversely; e.g., ≥76 years compared with ≤60 years: OR, 0.28; 95% CI, 0.13 to 0.62; p = 0.002). Correspondingly, for the No-SA-Expecting Group, higher age was also inversely associated with regaining postoperative SA (e.g., ≥76 years: OR, 0.07; 95% CI, 0.02 to 0.21; p < 0.001).

Conclusions: Of the patients who expected to be sexually active after surgery, 43.5% perceived this expectation to be unfulfilled; 24.3% were still sexually inactive despite most having expected a return to normal SA. Approximately one-fifth of patients who did not expect postoperative SA in fact regained SA. During preoperative consultations, surgeons should pay attention to expectation management surrounding SA.

Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

1Departments of Biomedical Data Sciences (H.P.), Orthopaedics (R.T.E.H., C.S.L., and R.G.H.H.N.), and Urology and Medical Decision Making (H.W.E.), Leiden University Medical Center, Leiden, the Netherlands

2Center of Research on Psychological and Somatic Disorders, Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands

E-mail addresses for R.T.E. Harmsen:;

Investigation performed at the Departments of Orthopaedics and Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands

Disclosure: Funding was obtained from the Dutch Arthritis Association (LLP13). The funding source had no role in the study design, collection, analysis, and interpretation of data, writing of the manuscript or the decision to submit the manuscript for publication. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (

© 2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The Journal of Bone and Joint Surgery, Incorporated.