Importance There are limited data describing the impact of total knee arthroplasty (TKA) on postoperative sexual activity. This lack of information may lead to inaccurate preoperative expectations and predispose patients to dissatisfying outcomes with respect to sexual activity.
Objective The objective of this systematic review was to determine: (1) How important is sexual activity to patients undergoing TKA? (2) How will TKA impact a patient’s postoperative sexual activity?
Evidence review We performed a comprehensive search using PubMed, Scopus and Ovid databases to identify literature relevant to sexual activity following TKA. Publications were identified and sorted using our inclusion/exclusion criteria. Data were normalised and segregated for qualitative description.
Findings We identified eight studies that met our inclusion/exclusion criteria. Patient populations, study objectives and findings varied greatly between studies. With respect to the importance of sexual activity among patients undergoing TKA, results were highly polar, with some studies indicating that sexual activity was among the most important activities, and others reporting it among the least important. With respect to the ability to return to sexual activity after TKA, patients listed engaging in sex as one of the least difficult activities postoperatively, and fewer patients had to adjust their sexual positions to accommodate their knee. About 50%–77% of patients experienced no change in the quality/frequency of sex as a result of TKA, 6%–44% experienced an increase, 6%–32% reported decreases and 2%–23% experienced a cessation of sexual activity. However, outcomes with respect to sexual activity often failed to meet patients’ preoperative expectations.
Conclusions and Relevance Studies reporting on the US population with representative male/female distributions reported that sexual activity was highly important to patients, although this finding may not be globally generalisable. While data regarding changes in sexual quality/frequency are variable, studies with longer average follow-up time and younger patient populations tended to report better outcomes. These results likely indicate that younger populations will experience more favourable changes in sexual activity as a result of TKA, and that improvements in sexual quality/frequency will continue as follow-up time increases. Furthermore, patients undergoing TKA are likely to return to sexual activity at 2.4months.
Level of evidence Level III.
- Knee (Anatomic Location)
- Rehabilitation/Physical Therapy (Orthopaedic Sports Medicine)
- Arthroplasty (Treatment/Technique)
- Total Joint Replacement (Treatment/Technique)
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- Knee (Anatomic Location)
- Rehabilitation/Physical Therapy (Orthopaedic Sports Medicine)
- Arthroplasty (Treatment/Technique)
- Total Joint Replacement (Treatment/Technique)
What is already known
Patients undergoing total knee arthroplasty (TKA) may have inaccurate expectations regarding sexual function and sexual experience after surgery, and these misperceptions may drive dissatisfaction after surgery.
While postoperative sexual activity following total hip arthroplasty (THA) is well documented, there are limited data describing sexual activity following TKA.
TKA has been shown to decrease difficulty during sex and decrease the proportion patients who had to adjust their sexual positions to accommodate their knee during sex.
While many patients report increases in the quality and frequency of their sexual experiences following TKA, a roughly equivalent number of individuals report decreases in quality/frequency.
What are the new findings
Data regarding changes in sexual quality/frequency are variable; studies with longer average follow-up time and younger patient populations tended to report better outcomes.
These results likely indicate that younger populations will experience more favourable changes in sexual activity as a result of TKA, and that improvements in sexual quality/frequency will continue as follow-up time increases.
Total knee arthroplasty (TKA) is regarded as the gold-standard treatment for end-stage osteoarthritis of the knee, and has generally been heralded as one of the most successful surgical interventions for pain relief. Despite overwhelming data demonstrating the ability of TKA to reduce pain and restore normal knee function in properly indicated patients, recent studies have reported that dissatisfaction rates after TKA often approach 15%.1–3 These paradoxical findings have been partially attributed to the fact that surgeons tend to rely on objective scoring systems that emphasise physician-reported data,4–10 which may overlook patient-centred outcomes.
In order to more accurately assess subjective patient-reported outcomes and pinpoint sources of dissatisfaction, recent efforts have been made to focus on alternative measures when assessing the results of surgery.1 11–15 Such alternative outcome tools have focused on advanced activities of daily living, mental health, socioeconomic well-being, return to work and athletics and sexual activity.16–43 These factors will only grow in relevance as utilisation of TKA expands into younger, healthier and more active patient populations.44–47
While sexual activity has been extensively studied in the setting of total hip arthroplasty (THA), from studies assessing the impact of THA on sexual quality/frequency and erectile function, to motion-capture studies assessing implant stability and impingement during different sexual positions,18 48–51 it is poorly described in the setting of TKA. As a result of this relative lack of information, educating patients and mediating expectations with respect to knee function after surgery is difficult. Previous studies have demonstrated a large disconnect between preoperative expectations with respect to sexual function and patient-reported postoperative results, with a greater number of patients experiencing decreases in sexual function than predicted.17 Because preoperative expectations play a significant role in postoperative satisfaction following TKA,13 mediating these expectations with accurate portrayals of postoperative sexual quality and frequency may play a role in improving satisfaction.
The purpose of the current systematic review is to summarise the current findings with respect to sexual activity after TKA. Guided by the available literature, we focused on two questions: (1) How important is sexual activity to patients undergoing TKA? and (2) How will TKA impact a patient’s postoperative sexual activity? This information may be valuable for educating patients regarding postoperative sexual activity, allowing surgeons to modify preoperative expectations.
Materials and methods
This systematic review did not require Institutional Review Board or ethics approval. It was performed in adherence with the PRISMA statement detailing the guidelines for systematic reviews.52–57 No external funding was provided for the completion of this study.
Three databases were used for this systematic review: PubMed, Scopus and Ovid. PubMed and Scopus were queried using the keywords ‘total + knee + arthroplasty + sexual’ using the ‘Basic Search’ function. The Journals@OvidFullText Database was queried in Ovid using the ‘Multi-Field-Search’ function using the search terms ‘sexual’, ‘total + knee’ and ‘knee + arthroplasty’. This search was performed in October 2016. No temporal limitations were placed on this search.
Query results were then imported into EndNote X7 (Thomas Reuters, 2015) and deduplicated, as previously described.58 The two coauthors of this review then screened each of the unique sources identified in our database query by title and abstract. Furthermore, relevant references of the included studies were assessed to determine if they cited relevant sources that we did not detect in our database query. Due to our conservative search criteria, the vast majority of these sources were not relevant to the current study. Relevant articles were reviewed in full for eligibility according to our inclusion/exclusion criteria.
Sexual activity is a relatively new outcome measure in the context of TKA, and no standard surveys or questionnaires have emerged as the gold standard for routine investigation of this outcome. As a result, individual studies tend to rely on their own specially developed surveys to assess this outcome, complicating interstudy data comparison and aggregation. In addition, many of the available studies regarding sexual function after TKA discuss subgroups of a specific ethnicity, sex or age, further hindering attempts at data pooling and meta-analysis. With this in mind, we developed broad inclusion criteria for this systematic review in order to allow for a thorough discussion of the available data of this relatively new area of study. No restrictions were placed on the patient populations, methods of comparison or study design. No restrictions were placed on the intervention or the methods of outcome measurement, so long as studies discussed sexual activity after TKA. Inclusion criteria were: 1) quantifiable results discussing sexual function after TKA and 2) data published in a peer-reviewed journal. Studies were excluded if they 1) did not present quantifiable results discussing sexual function after TKA or if they 2) were not peer-reviewed and published.
Through our literature search, we were able to identify 14 records in PubMed, 29 in Scopus and 192 in Ovid, yielding a total of 235 records identified through database searching. An additional record, which was written by the authors of this paper and was accepted for publication but was still pending release at the time that this systematic review was written, was also identified in our literature review.
After duplicates were removed, the coauthors of this review screened each of the unique 216 sources by title and abstract. Thirty-nine articles were identified as potentially containing data describing postoperative sexual function after TKA, and these texts were reviewed in full for eligibility. Ten of these studies met the inclusion/exclusion criteria, one of which was eliminated because it did not discuss subject matter relevant to this systematic review,13 and another because it presented the exact same patient data in a PhD thesis16 as a subsequent publication by the same author in a peer-reviewed journal.17 As a result, a total of eight papers were included for analysis, which are summarised in table 1.
The PRISMA flow diagram detailing the screening of these articles is shown in figure 1.
Importance of sexual activity after TKA
Weiss et al12 developed, validated and implemented an alternative outcomes survey called the Total Knee Function Questionnaire to assess patient function following TKA during baseline activities, advanced activities and recreational activities, including sexual activity. Patients were questioned regarding the frequency of each activity, the level of importance of each activity and the level of impairment for each activity as a result of their TKA. Using these metrics, sexual activity was ranked in terms of relative importance and relative impairment compared with other activities after TKA.
Forty-eight per cent of patients engaged in sexual activity following TKA, making it the 10th most prevalent of the 16 activities assessed in this study. When the importance of activities was expressed as a percentage of patients who participated in each activity, however, 62% of patients reported participating in sexual activity, making it the single most important of the 16 activities assessed. Seventy per cent of patients experienced normal knee function with no impairment during sex, making it the second least impaired activity of those studied. Only 14% (fourth lowest) of patients stated that they experienced moderate-to-severe difficulty (see online Appendix table 1 for complete list of activities ranked in this study).
In a similar study to that of Weiss et al,12 Noble et al21 prospectively assessed the importance and impairment of 16 different activities between postoperative TKA patients and healthy age-matched, sex-matched controls. Again, sexual activity was ranked in terms of relative importance and relative impairment compared with other activities after TKA. A modified version of the previously developed Total Knee Function Questionnaire12 was used. Composite Knee Function Scores, assessed by combining the frequency of each patient’s participation in a given activity, its perceived importance and the level of difficulty associated with performing that function, were also assessed.
Overall, 41% (ninth) of healthy controls took part in sexual activity, while about 37% (eighth) of TKA patients participated in sexual activity. These differences were not statistically significant. Expressed as a percentage of all individuals who participated in each activity, 67% of controls participated in sexual activity (second), while 72% (first) of TKA patients participated. These differences were not statistically significant. With respect to the proportion of patients experiencing symptom-free sexual activity, 86% (fifth) of controls experienced no issues during sex compared with 64% (second) of postoperative TKA patients. These differences were not statistically significant. Five per cent (seventh) of controls experienced moderate-to-severe difficulty during sex compared with about 13% (ninth) of TKA patients. This increase in the proportion of patients experiencing moderate-to-severe difficulty during sex was statistically significant (p<0.05). Differences in the Composite Knee Function Scores for sexual activity were statistically higher in healthy controls (p<0.05), although they both ranked similarly, with scores actually ranking relatively higher in TKA patients (fourth) than in healthy controls (fifth). Overall, men over the age of 85 had particular difficulty engaging in sexual activity. Results are summarised in table 2 (see online Appendix table 2 for complete list of activities ranked in this study).
Kim et al59 prospectively assessed the functional disabilities and satisfaction of female Asian patients following TKA, a population that is traditionally dependent on high-flexion activities.60 This study assessed the associated difficulty and perceived importance of 20 different functional activities, including sex. Results for difficulty and importance were presented as scores between 0 and 10, which were then used to order these activities in terms of difficulty and importance. This study also assessed differences between satisfied and dissatisfied patients to determine if these groups of patients differed in their relative difficulty or perceived importance of the activities studied.
This study found that sexual activity was the fourth most severely impacted function out of the 20 that were assessed, yielding a difficulty score of 4.1 out of 10. Despite the high level of difficulty associated with sexual activity, its difficulty rank did not correlate with its perceived importance in this patient population. In terms of patient-perceived importance, participation in sexual activity ranked 18th out of 20 activities assessed, scoring a 4.6 out of 10. In a subsequent analysis, sexual activity was ranked as the 4th most severely impacted activity in both satisfied and dissatisfied patients, and was ranked 18th and 20th, respectively, among satisfied and dissatisfied patients according to perceived importance (see online Appendix table 3 for complete list of activities ranked in this study). These differences between satisfied and dissatisfied groups were not statistically significant, indicating that differences in impairment of sexual activity or relative importance of sexual activity were not likely drivers of dissatisfaction.
Scott et al61 performed a prospective cohort study to examine whether patient expectations were fulfilled following TKA. Fulfilment of expectations with respect to 17 activities, including sexual activity, was assessed. Expectations were categorised as ‘fulfilled’ if they were fulfilled ‘greatly’ or ‘a lot’ at follow-up. Individual patient fulfilment was assessed by determining if expectations that were deemed ‘very’ or ‘somewhat’ important were fulfilled after TKA.
This study reported that prior to surgery, postoperative sexual activity was not a major concern, as it was the 16th most important of 17 variables under study. Only about 14% of patients found expectations relating to sex to be very important. Postoperatively, TKA exceeded sexual activity expectations, where 23% of individual expectations were met and 58% of the overall population’s expectations were fulfilled (see online Appendix table 4 for complete list of activities ranked in this study).
Return to sexual activity following TKA
Nordentoft et al49 performed a prospective analysis of male patients following THA or TKA to assess preoperative and postoperative sexual activity and erectile function. A specially designed survey was designed, tested and administered to patients before and after TKA. A total of 72 patients returned the preoperative survey, 52 of whom were sexually active and 21 of whom were not. Results of this study were not segregated by procedure (THA vs TKA). As a result, the findings presented in this systematic review include both patients who underwent THA and TKA.
This study determined that 17% of patients who were sexually active prior to surgery ceased sexual activity after joint arthroplasty, and the remaining 83% of patients experienced no change in sexual activity. Of this 83%, 57% were sexually active prior to surgery and experienced no change in sexual activity after surgery, and the remaining 26% were not sexually active before surgery and experienced no change in sexual activity. Therefore, a total of 74% (57%+17%) of this patient cohort were sexually active prior to surgery. Among the sexually active patients in this cohort, 23% (17%/74%) ceased sexual activity while 77% (57%/74%) experienced no change. No patients who abstained from sexual activity prior to surgery gained sexual function as a result of surgery. Patients who were not sexually active (n=14), as well as the 17% of patients who lost their sexual function after surgery (n=9), were significantly older than the rest of the study cohort (p<0.01).
The 30 patients who retained sexual activity and the nine patients who lost sexual activity after surgery were further assessed for changes in erectile function. Twenty-six per cent (6/23) of patients with normal preoperative erectile function experienced diminished erectile function after surgery, while 7% (1/16) experienced increased erectile function. Patients who maintained erectile function after surgery were significantly younger (p<0.02) than patients who lost erectile function after surgery and those who had erectile dysfunction before surgery, as shown in table 3.
Nunley et al18 retrospectively administered specialised questionnaires over the telephone to postoperative TKA patients in a multicentre study assessing the impact of surgery on sexual activity in young active patients, with an average age of 54.2 and a maximum age of 60. Surveys were administered by a third-party call centre, and focused on assessing sexual quality, frequency and limitations.
Nunley et al18 determined that 84% (430) of patients reported returning to sexual activity, while 2% (8) of patients reported that they had not returned to sexual activity as a result of their knee. Sixty-six per cent (275) of patients reported having the same amount of sex, 10% (40) reported having less sex and 25% (103) reported having more sex. Among the patients who reported having more sex, 99% (102) attributed it to decreased pain, 95% (98) to greater mobility and 70% (69) to decreased apprehension about the knee during sex. Fifty per cent (208) of patients reported no change in the quality of their sex, and 6% (25) reported a decrease in the quality of their sex. Forty-four per cent (182) reported improvements in the quality of their sex, resulting from less pain in 98% (179), greater mobility in 92% (167) and less apprehension in 61% (109). Sixteen per cent (68) of patients had to limit their sexual activity as a result of their knee, and 11% (47) felt instability of the knee during sexual activity.
Klit et al16 17 prospectively assessed standard and alternative outcome measures after TKA, including the impact of TKA on sexual activity, in a young (aged <60 years) patient cohort. In this multicentre study, a specially designed 7-question survey was validated and used to study postoperative sexual function. Questions from this survey focused on the positive/negative impacts of TKA on sexual frequency and practice.
Findings from this study demonstrated that TKA improved the proportion of sexually active patients from 83% (95/115) preoperatively to 94% at 12 months follow-up (62/66), with 62% of these patients (41/66) being able to resume sexual function by 8 weeks after surgery. Despite these positive improvements in the proportion of patients able to participate in sexual activity, these outcomes fell short of preoperative expectations. While 21% (19/95) of patients expected TKA to have a positive impact on their sex life, at 12 months only 6% (4/62) experienced a positive change. Furthermore, while only 7% (7/95) expected TKA to negatively impact their sexual activity, 32% (20/62) experienced a negative change at 12 months. This difference between preoperative expectations and postoperative reality was statistically significant (p<0.0001).17 No differences were found between males and females. There were no differences in sex-related outcomes between the unilateral and bilateral TKA subgroups.
Kazarian et al62 developed a specialised survey to retrospectively assess the impact of TKA on patients’ positional liberty during sexual intercourse. Patients were retrospectively contacted over the phone, via email or in clinic to discuss sexual limitations. Questionnaires asked patients to describe their postoperative sexual function, describe if/how sexual experiences improved/worsened >12 months after surgery and to recall details regarding preoperative sexual function.
Prior to TKA, sexual quality/frequency was limited due to knee pain and discomfort in 45% of patients. On average, patients experienced 17.1 months (range 0–60) of sexual limitations prior to TKA. Limitations arose primarily from pain (87%) and diminished range of motion/flexibility (44%). Fifty-five per cent of patients reported the need to change their sexual positions in order to accommodate their artificial knee, with 97% of these patients indicating the need to avoid kneeling during sex.
Postoperatively, patients resumed sexual activity after an average of 2.4 months (range 0–18). Patients experienced vast improvements in positional liberty, with fewer patients having to adjust their sexual positions to accommodate their knee (55% vs 28%, p=0.0005). In addition, fewer patients had to avoid bearing weight on the afflicted knee during sex (97% vs 79%, p=0.02).
Despite these general improvements, 7% of individuals had less sex in the first year after surgery, an additional 16% stopped having sex, 62% reported no change and only 15% reported increases in sexual activity. After 1 year of recovery, however, 60% indicated that they more easily engaged in sexual activity than in the previous year, with 84% of these patients experiencing less pain, and 30% experiencing greater mobility or range of motion.
The literature describing postoperative sexual function after TKA is largely centred around two topics: 1) the importance of sexual function to patients undergoing TKA and 2) the impact of TKA on sexual frequency/quality. These findings are discussed and interpreted below.
Importance of sexual activity to the TKA patient
With respect to the importance of sexual activity to the TKA patient, the published literature is highly discordant. Results from Weiss et al12 and Noble et al21 both demonstrated that sexual activity is the single most important activity (of the 16 activities assessed in each study) to patients undergoing TKA. Results from Kim et al59 and Scott et al,61 however, rank sexual activity in the lowest two activities of interest. These differences could be due to differing demographics under study in these publications, as the studies by Kim et al and Scott et al had higher proportions of female subjects (61% and 100%, respectively) compared with Weiss et al and Noble et al (40% and 54%, respectively). Differences could also be due to cultural variation, as the population in Kim et al was restricted to Asian women and the population in Scott et al was limited to patients in the UK, while populations in Weiss et al and Noble et al were composed of patients in the USA.
Regardless of the aetiology, such inconsistent results make it difficult to identify the true importance of sexual activity to patients undergoing TKA. Given that the demographics represented in Weiss et al and Noble et al represent a more even male/female distribution and are reflective of the cultural groups that predominate the US population, they are likely to be more reflective of the opinions held by patients undergoing TKA in the USA. Furthermore, if TKA patients have similar views compared with THA patients regarding the importance of sexual activity after surgery,63 a reasonable assumption given the similar patient populations that undergo these procedures, findings from Weiss et al and Noble et al are likely to more accurately describe the high importance of returning to sexual activity among patients undergoing TKA.
Impact of TKA on sexual frequency/quality
Despite what clinicians and patients may expect, the impact of TKA on sexual activity is mixed. This systematic review identified many positive findings regarding sexual activity after TKA. First, Weiss et al12 and Noble et al21 both found that engaging in sexual activity was the second least impaired activity of the 16 assessed in each of these studies, demonstrating that patients can engage in sexual activity with relative ease following TKA.
In line with these findings, a large proportion of patients who were sexually active prior to surgery appear to maintain sexual activity after TKA. Findings demonstrate that 50%–77% of patients should expect no change in the quality/frequency of sex as a result of TKA, and that 6%–44% should expect an increase16–18 49 62 (table 4). Improvements in the frequency and quality of sex can be attributed to decreased pain (99% and 98%, respectively), greater mobility (95% and 92%, respectively) and decreased apprehension about the knee during sex (70% and 61%, respectively).18 After TKA, patients will likely experience diminished difficulty kneeling on the afflicted knee during sex, which may be accompanied by improvements in positional liberty. As a result, fewer patients will have to adjust their sexual positions to accommodate their knee after TKA. These sex-related outcomes will continue to improve > 1 year after surgery, mostly due to continued decreases in pain (84%), and continued improvements in knee mobility/range of motion (30%). On average, patients are likely to return to sexual activity at 2.4 months.62
Despite these positive findings, fewer patients experienced positive improvements and more patients experienced negative changes in sexual activity after TKA than expected in the early postoperative period.16 17 Between 6% and 32% of patients experienced a decrease in sexual activity, and 2%–23% experienced a cessation of sexual activity after TKA. Furthermore, as many as 26% of men after TKA may encounter de novo erectile dysfunction.49 Finally, men and women are 16% more likely to limit their sexual activity because of their knee, and 11% are likely to experience feelings of instability of the knee during sex.18
These wide ranges in the published literature with respect to the proportion of patients who ceased or decreased sexual activity after TKA can likely be attributed to differences in the demographic groups that were included in each study. Nordentoft et al,49 the study with the highest average age (71 years) and shortest follow-up time (6 months), demonstrated the greatest proportion of patients who ceased having sex and the highest proportion of patients who experienced no change in sexual activity. When assessing differential findings in the proportion of patients who experienced increases and decreases in the quality/frequency of sex after surgery, Klit et al,16 17 the study with the shortest follow-up time (12 months), reported the highest proportion of patients who experienced a decrease in sexual quality/frequency (32%) and the lowest proportion that experienced an increase (6%). This explanation is corroborated by findings by Nunley et al18 and Nordentoft et al,49 which demonstrated a greater loss in sexual activity and greater risk of erectile dysfunction with increasing age, and findings from Kazarian et al,62 which demonstrated that sex-related outcomes continue to improve >1 year after surgery.
There are limitations to this study. We were only able to identify eight relevant peer-reviewed publications on this topic, as it is a relatively new area of interest. Further complicating this limited data set was the lack of homogeneity in survey materials and outcome measures used to assess postoperative sexual function, as well as conflicting intrastudy results and conclusions. Finally, the majority of studies were conducted in TKA patients in the USA, and future studies evaluating sexual activity after TKA should be conducted in other patient populations to assess the impact of culture on this alternative outcome measure.
The importance of sexual activity to patients undergoing TKA is likely to be important to patients in the USA with representative male/female distributions. Patients undergoing TKA are unlikely to experience changes in sexual function, with relatively even numbers of patients experiencing increases or decreases in sexual function. Age is the most likely determinant for changes to sexual function after TKA. Finally, TKA patients should expect continued improvement in sex-related outcomes as follow-up time increases. Future work should focus on identifying the factors that predispose individuals to poor sex-related outcomes after TKA. Furthermore, TKA patients are likely to return to sexual activity at 2.4 months.
Contributors Both authors have contributed substantially to this manuscript.
Competing interests None declared.
Competing interests Commissioned; externally peer reviewed.
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