BHR anterior / posterior approach and clunking

[alay111]

I am 4 years on with bi lateral BHR in which the surgeon used a posterior approach. In New Zealand I cannot find any surgeons who use a anterior approach. I am wondering if anyone out there has had a BHR using the anterior approach and have had any issues with clunking?
Asking various surgeons who use the posterior approach, they say around 20% of their patients experience clunking. I have various thoughts as to why their patients experience clunking but I need to do a lot more research into this (I know about IT band issues but have reason to believe it is more than this) and the comparison between the anterior and posterior approach wrt clunking may give me some different ideas to consider. Many thanks to all who reply.

[chuckm]

The clunking is caused by deep ligaments that slip across the pelvis that clunk when they do. It can happen to people who have dislocated their hips. Hip resurfacing is carried out by dislocating the hip (anterior or posterior approach) and so the clunking can occur.

I have clunking but it does not adversely affect anything.

Chuckm

[Dannywayoflife]

Chuck covered it all in his post. I had clunking in my left side and have a little in my right. I found last time after about 6 months it pretty much dissapears.

[MattJersey]

I have noticed that clunking when walking or doing exercises. Physio said to me last week when doing a squat type of exercise to tighten my butt cheeks, imagine trying to crush a walnut in them. This seems to work to stop it, and when walking, tightening the butt through the stance on the new hip too.

That reassures me that it isn't the hip joint flopping around at all, and over time, with doing the exercises (which include butt clenching), it will resolve itself as the muscles regain control of things.

[jss]

I'm 4 months post-op and like everyone else that's posted, I have the same clunking.  It's pretty common.  I only notice it when I'm standing and shifting my weight in certain ways.

[alay111]

The clunking is caused by deep ligaments that slip across the pelvis that clunk when they do. It can happen to people who have dislocated their hips. Hip resurfacing is carried out by dislocating the hip (anterior or posterior approach) and so the clunking can occur.

I have clunking but it does not adversely affect anything.

Chuckm

The majority of hip dislocations and a hip resurfacing posterior approach are very similar with regards to hip movement, the hip moves out of the joint in a posterior direction. Damage to the joint capsule posteriorly and other posterior structures (muscles, ligaments, tendons etc eg the glutes and rotators) can be very similar. Clunking does occur in both but it is because similar structures are damaged during the process.
Using an anterior approach, the hip is moved forward out of the joint which spares the cutting / separation of the structures at the rear of the hip.  If the posterior structures are damaged to a much lesser degree, which they are with an anterior approach, is the incidence of clunking the same, greater or less?
If it is less then we could conclude that clunking is related to the surgical approach and the subsequent changes in the posterior structures. Understanding this could lead to either modifications of the surgical approach (yes, I have discussed this with a number of surgeons and they are very interested in what I find out as it seems no one has asked this question before to their knowledge) and or additional / different pt exercises that focus on the cause of the clunking (and since day one I have believed that clunking is not due to the joint flopping around but because of structures sliding across the joint faces, not that different to boxer's knuckle which is very well understood).
So back to my original question - do you know what approach your surgeon used if you have clunking?

[MattJersey]

Procedure W3715, which is a standard posterior approach.

And I have a little clunk now and then, doesn't feel like anything might dislocate, but I guess until (and if) that happened I wouldn't know!

[John C]

Hi alay111.  Here is my report on clunking.
I had the posterior approach about 7 years ago, and have experienced three distinctly different sensations, any of which I think people sometimes refer to as clunking.
The first couple of weeks after surgery, there was often a very distinct deep clunk, which I am quite sure was the two metal surfaces separating slightly and then recontacting. This was attributed by my surgeon to the soft tissue not being strong or toned enough to keep the surfaces in constant contact. This was mostly in the first week or two, and went away after the first couple of months.
The second is a subtle slipping of the two surfaces against each other. In this case the two surfaces remain in solid contact, but because the prostheses have a "polar" contact as opposed to a surrounding connection, that polar contact point will sometimes slip a fraction of a millimeter which is like an extremely subtle clunking. This still happens rarely, and is not at all a problem.
The third sensation is not what I think of as a clunk, but I know some people call it that. This is when I feel soft tissue bands (tendons or muscles) sliding or snapping across each other, or other structures. This is something that I continue to experience on a regular basis when doing deep lunges or deep squats, and is definitely uncomfortable. Since this sensation does not have a metallic connection involved, I don't think of it as a clunk, but it is the one "shifting" sensation that has not changed with time.
In my mind, this third one is definitely related to the posterior approach, since the soft tissue where I feel the shifting is definitely in the surgical plane deep under the external scar.
It will be interesting to see if you can get any of the top resurfacing surgeons involved in a discussion about the anterior approach. Up until now, they seem reluctant to discuss it. They know that cup placement is critical, and are reluctant to change to an approach that they do not feel gives them as much confidence with that cup placement.
Good for you for trying to get the conversation going. Hope it leads somewhere.

[hernanu]

Always good to get a discussion going.

Dislocation is a major component (about 25%) of THR revisions (total hip).

The good news for us resurfacing types is that for HRs, it's a small component of all revisions. From the 2014 Australian registry, the percentage of revisions due to dislocation is at 2%.

(See included graph for all revisions and their cause).

[karlos.bell]

  Hi there Alay111.
Clunking yep mine do- or what would I describe as load to fluid shift. They do it mostly on non weight bearing action. A small clunk or click. No Pain and to be expected. It is a mechanical device with a fine tolerance. The Labrum normally deepens the socket so in this transitional phase the ball dose  shift in load movement as the labrum normally makes the socket real deep. You have not got a labrum anymore so it can move slightly. That's my take on it anyway and that's what I have expected a bit of clunking at times.

Approaches mine was posterior and they move the Piriformis muscle / tendon out of the way. So they stitch it back up later on.
Hey my old hips used to move around and pop and click but they had pain associated with these hips. These ones are mechanical so they do not have that issue. Email me as I am in NZ if you would like. I am only 4 weeks post op but things are going to plan. Kind Regards K