Background and Significance
Johnson's behavioral system model states that an individual's behavior is predictable, purposeful, and organized when his or her behavioral system is balanced. Imbalance occurs when there are stressors and tension that affects the subsets of the individual's behavioral system. An example of this would be the stressor of a posterior total hip arthroplasty (THA) on sexual activity (Tomey & Alligood, 2006). Sexual activity is a quality-of-life issue among those individuals who have undergone a THA (Dahm, Jacofsky, & Lewallen, 2004).
In their study, Laffosse, Tricoire, Chiron, and Puget (2007) state that few studies examine issues related to sexual activity of patients who have been affected by a THA. Laffosse et al. (2007) reveal that there are a couple of reasons that explain this lack of discussion between the practitioner and the patient regarding this topic. For example, the practitioner may feel that this is an insignificant issue compared with the radiologic and physical findings of the patient. Second, the questions that are used to evaluate the outcomes of a hip replacement rarely address sexual activity and how it relates to a THA (Laffosse et al., 2007). Akkus, Nakas, and Kalyoncu (2010) conclude that other barriers related to discussion of this topic range from cultural, social, and religious beliefs. Dahm et al. (2004) express that physicians and practitioners may be reluctant to have this discussion with their patients for a couple of reasons. These reasons can range from lack of guidelines to the uncomfortable feeling felt by both the practitioner and the patient when approaching such a delicate topic. Not only is sexual activity a quality-of-life issue regarding THA, but the fear of hip dislocation is a reality faced by this patient population. Patients who have undergone a THA have three major rules they must follow so as not to dislocate their hip. These rules are as follows: avoid internal rotation of the affected leg, avoid bending the hip more than 90[degrees], and do not cross the legs or ankles (Best, 2005). The purpose of this literature review is to answer the question: In middle-aged patients who have undergone a posterior THA, is the supine position (missionary position) compared with other coital positions recommended in preventing hip dislocations?
Clinical Appraisal of the Literature
The primary methods for literature search include electronic databases through Western Kentucky University and Kornhauser Library. These studies and literature reviews included full-text research studies from peer-reviewed journals from 2002 to 2007. A study conducted by Stern et al. (1989) was used even though it was outside of the 10-year window. This study was used because it offered supporting evidence toward the research question and was also referenced in the current studies used for this literature review.
The nature of evidence confirms that sexual activity after a THA is an important quality-of-life issue. The review of literature reveals that sexual activity is safe to resume 1-2 months after a THA. Laffosse et al. (2007) go as far as to say that the only limit to resuming sexual activity after a hip replacement is that this particular act puts the patient at a high risk for dislocation. The recommended coital position at preventing hip dislocation is the supine (missionary) position. In their study, Aikawa et al. (2004) confirm that the supine position at maximum abduction in extension is the safest position for preventing posterior hip dislocation during sexual activity. The lateral decubitus positions are not recommended because of the high risk of adduction and internal rotation of the hip. If the hip is adducted and internally rotated during sexual activity, the patient is at a greater risk for hip dislocation (Laffosse et al., 2007).
Although the majority of the literature recommends the supine (missionary) position, one study concluded that there are several safe positions for both men and women. In their study, Dahm et al. (2004) asked surgeons to review 12 coital positions and decide which position was the safest at preventing posterior hip dislocations. The results showed that there were five positions acceptable for the man and three positions for the woman who had undergone a THA. The one position that 90% of the surgeons agreed upon to be the safest position for either the man or woman was that the man and woman are both standing with the woman slightly bent at the waist and the man approaches the woman from behind (Dahm et al., 2004).
In their study, Stern et al. (1989) concluded that taking a more passive role in the supine position a few weeks after a THA was the best way to prevent a posterior hip dislocation. But they also concluded that the most comfortable position for the male patient was the prone position (patient on top) and that female patients preferred the side-lying position (decubitus position). Stern et al. (1989) agree with Dahm et al. (2004) that there is more than one coital position that can safely be taken if posterior hip precautions are observed.
There were only two educational articles and six research articles related to this particular topic. Because of the nature of this topic, little research has been conducted. The majority of the studies looked at lack of knowledge related to sexual activity after a THA, how does the THA improve the lives of the patient, and how does the THA affect the quality of sexual experiences of the patient. It is recommended that more studies are needed on the topic regarding which coital position is safe after a THA in preventing posterior hip dislocation (see Table 1).
|Table 1-a. Research Grid|
Clinical Practice Implications
In their study, Stern et al. (1989) concluded that 65% of the patients would have found a discussion with their surgeons beneficial. Meyer et al. (2003) determined that there is a need for better education regarding sexual activity after a THA for both the patient and the partners. Altizer (2004) wrote that Whittington recognized this need and devised a booklet titled "Sex After Total Joint Replacement." Laffosse et al. (2007) support Whittington in stating that safe coital positioning should be stated clearly and, if necessary, the explanation should be accompanied by diagrams. Therefore, it is imperative that the practitioner educate the patient and the partner on safe coital positioning during sexual activity (Akkus et al., 2010). This is also the responsibility of the orthopaedic nurse. Nursing can reinforce posterior hip precautions, the safe time to return to sexual activity, and which position is safe at preventing posterior hip dislocations. Another nursing implication would be to educate the patient and the partner what to do if the hip dislocates during sexual activity. By opening this door to such a taboo subject, patients can become empowered to discuss other issues that may seem uncomfortable to patients regarding their healthcare.