Sex After Hip Surgery: Advice That Patients May Not Receive

Neil Chesanow


November 30, 2015

Which Sexual Positions to Recommend

Patients who have had THR must follow three rules to avoid hip dislocation: Avoid internal rotation of the affected leg, avoid flexing the hip more than 90 degrees, and avoid crossing the legs and ankles.[2]

Sexual positions that respect these rules are permissible, although most recommendations are based on expert opinion, not biomechanical research.[2]

One study recommended the supine (missionary) position for both women and men who had THR because the risk of dislocation is low.[13] In another study, investigators asked surgeons to decide which coital positions were safest at preventing posterior hip dislocations.[14] They came up with five acceptable positions for men and three for women. But the one that 90% deemed safest for both men and women was both partners standing, with the woman slightly bent at the waist and the man approaching the woman from behind.

Charbonnier and colleagues did an in vivo study using optical capture and magnetic resonance imaging (MRI) to accurately determine hip joint kinematics during post-THR coitus.[15] Twelve common sexual positions were evaluated. Most sexual positions for women required flexion, abduction, and mostly external rotation. For men, flexion and abduction remained in the normal range, but external rotation was dominant for all positions. Impingements that may cause prosthesis dislocation occurred in sexual positions for women requiring the highest hip flexion combined with abduction; sexual positions for men required less mobility and were considered safer.

The study found that for women, rear penetration; the woman on top and leaning forward; face-to-face sidelying ("spooning"); and the woman lying supine with knees flexed and legs apart, with the man's hips under the arch formed by the woman's legs, were best avoided.[15] For men, the face-to-face sidelying position carried the greatest risk of impingement and prosthesis dislocation.

Dr Luu explains that the safety of sexual positions depends on the approach used by the orthopedic surgeon for the procedure.

"A direct anterior approach, for example, is a very stable construct in that the risk of dislocation is less than with a posterior approach--but still possible," Dr Luu says. "With an anterior approach, we don't want patients to maximally externally rotate, or turn their foot out maximally. That forces the ball to come interiorly. So positions that put the person who had a hip replacement in that situation would be at risk causing for dislocation even though the risk is much lower from anterior approach for a total hip replacement."

"If it’s a posterior approach, the opposite is true," Dr Luu continues. ”You don’t want to flex the hip past 90 degrees and internally rotate the hip or turn the foot in. That puts the hip at risk for coming out the back and could lead to dislocation. Those key precautions dictate what positions are safe in general."

"Whether it’s the male or female who had the hip replacement, with a posterior approach, if you keep your legs apart, that’s safe and so less likely to dislocate," Dr Luu says. "And then you don’t want to bend the hip all the way up to where the hip is flexed past 90 degrees. If it’s a posterior approach, then that would risk dislocating out the back."

Dr Lajam actually has figures illustrating safe sex positions after THR posted on her website.[1] They include the missionary position, suitable for both men and women who have had THR; backlying position suitable for women who had had THR, in which the woman lies on her back with her legs over her partner's hips; sidelying position for both men and women; woman on top, man on the bottom--with the top position safe for women and the bottom position safe for men; backlying position, in which the women with THR has her back propped up by pillows and her partner is kneeling between her legs; and the standing position, with the woman in front, torso slightly bent, and the man behind her, which is suitable for either the woman or man with THR.

This page has the most hits of any on her website, Dr Lajam says.

Dr Luu recommends giving THR patients a booklet, pamphlet, or information sheet with recommended sexual positions, such the Staywell Company's Krames Patient Education materials, which are widely adapted.[16]One example, used by Overlake Hospital Medical Center in Bellevue, Washington, explains four positions: face to face, with the man supine and the woman seated on top, a position safe for either partner with THR; sitting in a chair with the woman on top, straddling the man, which is safe for whichever partner has had THR; woman lying on the edge of the bed with her feet balanced on a stack of cushions while the man kneels between her legs; and the sidelying position.[17]

Patients are advised to take a mild pain medication about 20-30 minutes before sex, which can help prevent minor aches, and to avoid taking medication so strong that it masks warning pain.[17]