Ceramic-on-ceramic (CoC) THAs have excellent wear characteristics and are an attractive option in young patients [3, 5]. Case series of ceramic bearings have excellent patient-reported outcome scores for pain and function [1, 11, 14]. However, CoC bearings are used less commonly than conventional bearing surfaces, in part due to concern for the unique complications of ceramic components, namely squeaking and fracture [3, 8, 19, 23]. Squeaking is a problem that is, for the most part, unique to CoC bearing surfaces [9, 25]. Squeaking sometimes is an indication for revision, and therefore may negatively affect survivorship.
Risk factors for squeaking have been described, but there is no consensus regarding the specific patient and implant variables associated with squeaking. The proportion of CoC bearings that squeak appears to vary widely and has been reported to range from 0.5% to 36% [1, 2 ,9, 10, 11, 12, 17, 21]. Although prior studies defined the scope of the problem, the follow-up was often short, and therefore the proportion of CoC THAs that squeak at long-term follow-up is not well characterized. Squeaking is generally not associated with pain or decreased function, but few studies have compared validated patient-reported outcomes between squeaking and nonsqueaking CoC THA at long-term follow up.
We therefore asked (1) What proportion of patients treated with CoC THA bearings report squeaking at a minimum of 10 years of follow-up? (2) Are patient, implant, or radiographic factors associated with squeaking? (3) Are THAs that squeak more likely to be revised than those that do not? (4) Are patient-reported functional outcome scores lower between THAs that squeak and THAs that do not squeak at long-term follow-up?
Patients and Methods
This retrospective, observational study included all patients undergoing THA with third-generation alumina CoC bearing surfaces between January 1, 2003 and August 31, 2008 at the Naval Medical Center San Diego. This was an institutional review board-approved study.
During the 5-year period, 80 patients received THAs with third-generation alumina-on-alumina bearings; we attempted to contact all of them. Of the original 80, 1% (1 of 80) had died, and 21% (17 of 80) were lost to follow-up before 10 years, leaving 62 patients for analysis at a mean (range) of 14 years (11 to 16). Ceramic-on-ceramic THA was used preferentially in patients younger than 50 years of age. The mean (range) age of patients in the cohort was 44 years (18 to 65). Ceramic-on-ceramic THA represented 23% (80 of 343) of THA during the study period.
All patients who underwent THA with a CoC bearing at our institution during the study period were mailed an investigator-developed questionnaire (Fig. 1). The 10-question qualitative survey was marked with a unique patient identifier to ensure confidentiality. Patients were explicitly queried whether their THA had ever made a squeaking noise; any positive answer was recorded. Patients were asked to write in their description of the noise, for example, “squeak” “click”, “grind”, or “pop”. This was done to distinguish squeaking from other noises to avoid overestimating all THA noise as squeaking. Squeaking does not have a consistent definition, but is generally considered to be an easily distinguishable often high-pitched (400 Hz to 7500 Hz) sound [21, 24]. Participants were also surveyed regarding the onset of squeaking after surgery, frequency, inciting activities, association with pain, and effect on quality of life. The survey, although not validated, was similar to those used in prior studies examining the frequency with which patients report squeaking after CoC THA [10, 12, 15, 21].
Patient, Implant, and Radiographic Variables
Patient variables including age, gender, and BMI at the time of surgery were obtained via chart review by an investigator not involved in the index operation (KT). Implant variables were similarly collected from the operative record.
Standard AP radiographs of the pelvis (Fig. 2) were obtained 6 weeks postoperatively, and the component’s position was evaluated using validated Martell three-dimensional computerized imaging software (Chicago, IL, USA ) . The acetabular component was placed with a goal of 45 ± 10° of abduction and 15 ± 10° of anteversion. All THA were completed using a posterior approach without intraoperative navigation.
Patient and Implant Characteristics
Eighty patients who received CoC implants during the study period were identified from operative records using the Current Procedural Terminology (CPT) code for THA. We were able to contact 62 patients who underwent 72 THAs. Only the initial THA was included for analysis in the patients with bilateral THA. The median (range) follow-up from the index surgery was 14 years (11 to 16). The indications for index THA included idiopathic osteoarthritis (65%; 40 of 62), osteonecrosis (14%; 9 of 62), hip dysplasia or Perthes disease (8%; 5 of 62), posttraumatic osteoarthritis (8%; 5 of 62), and autoimmune disease (5%; 3 of 62) (Fig. 3).
Two separate manufacturers’ implants were included. The uncemented acetabular components included the Trident PSL (Stryker, Mahwah, NJ, USA) (n = 59) and Duraloc (DePuy-Synthes, Warsaw, IN, USA) (n = 3). The uncemented femoral components included the Accolade titanium-molybdenum-zirconium-iron (TMZF) stem (Stryker, Mahwah NJ, USA) (n = 46), SecurFit titanium-aluminum-vanadium stem (Stryker, Mahwah, NJ, USA) (n = 13), and S-ROM (DePuy-Synthes, Warsaw, IN, USA) (n = 3). All CoC bearings were third-generation alumina-on-alumina (Biolox® Forte, CeramTec, Plochingen, Germany).
Primary and Secondary Study Outcomes
The primary study outcome was the proportion of patients who reported CoC squeaking via patient survey at minimum of 10 years after surgery.
Secondary outcomes included differences in patient and radiographic variables, implant survivorship, and patient-reported outcome scores between squeaking and nonsqueaking THA. Patient and radiographic variables included age, gender, BMI, femoral head size, acetabular cup size, cup abduction, and cup anteversion. Implant survivorship was determined using the Kaplan-Meier survivorship estimator. The Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR), which includes six items regarding patient pain and function, was collected from all patients at most recent follow-up.
We used an independent-sample t-test to compare squeaking and nonsqueaking hips based on age, BMI, acetabular cup size, cup abduction, cup anteversion, and patient-reported outcome scores (HOOS JR). We used a chi square test was used to assess group differences in gender, and a Fisher’s exact test to determine differences in femoral head size. An odds ratio was used to study the distribution of femoral component type between the two groups. The level of significance was set at p < 0.05. We compared between-group survivorship free from revision for any reason at 10-year follow-up using the Kaplan-Meier survivorship estimator, and calculated 95% confidence intervals around the point estimates (Fig. 4).
Proportion of Patients who Reported Squeaking
Squeaking was reported by 53% (33 of 62) of patients. A total of 33% (11 of 33) of patients stated that squeaking symptoms began within the first year from index operation, while 39% (13 of 33) of THAs began squeaking more than 5 years after initial surgery. No patient reported painful squeaking. Seventy-nine percent (26 of 33) of patients with squeaking hips stated that their symptoms did not affect their quality of life.
Factors Associated with Squeaking
Squeaking was more common in patients who received the Accolade titanium-molybdenum-zirconium-iron stem (Stryker) than with the SecurFit stem (Stryker) (63% [29 of 46] versus 31% [4 of 13]; odds ratio 3.8 [95% CI 1.02 to 14.4]; p = 0.046). The combination of DePuy S-ROM stem and Duraloc cup (DePuy-Synthes) was used in only three THAs, none of which squeaked and were excluded from statistical analysis (Table 1). The mean cup abduction angle was not different between squeaking (47 ± 7°) and nonsqueaking groups (48 ± 7°]; p = 0.53). Mean cup anteversion was not different between squeaking (17± 6°) and nonsqueaking CoC hips (16 ± 6°; p = 0.38). Patient age, gender, and BMI at the time of the index surgery were not different between squeaking and nonsqueaking CoC THA bearings (Table 2). Additionally, median (range) femoral head size and distribution of use was not different between cohorts (32 mm [28 to 36] versus 32 mm [28 to 36]; p = 0.46) (Table 3).
Table 1. -
Proportion of THAs with squeaking, by femoral stem designa
||Accolade TMZF (n = 46)
||SecurFit titanium-aluminum-vanadium (n = 13)
||Odds ratio (95% CI)
|Percentage with squeaking
||3.8 (1.02 to 14.4)
aNote that three hips with S-ROM (DePuy, Warsaw, IN, USA) femoral stems are not included, as that number is too small to analyze statistically; Accolade TMZF (Stryker, Mahwah NJ, USA), SecurFit (Stryker).
Table 2. -
Patient demographics, component position/size for patients with squeaking and non-squeaking ceramic-on-ceramic implants
||Squeaking hips (n = 33)
||Non-squeaking hips (n = 29)
|Age in years ± SD
||42 ± 12
||45 ± 10
|BMI in kg/m2 ± SD
||28 ± 4
||29 ± 4
|Cup anteversion in ° ± SD
||17 ± 6
||16 ± 6
|Cup abduction in ° ± SD
||47 ± 7
||48 ± 7
|Cup size in mm ± SD
||55 ± 3
||54 ± 4
|Hip Disability and Osteoarthritis Outcome Score for Joint Replacement ± SD
||3 ± 3
||3 ± 5
Table 3. -
Distribution of femoral head sizea
||28-mm femoral head
||32-mm femoral head
||36-mm femoral head
|Squeaking CoC (n = 33)
|Non-squeaking CoC (n = 29)
aMedian (range) squeak versus non-squeak (32 mm [28 to 36] versus 32 mm [28 to 36]); p = 0.46); CoC = ceramic-on-ceramic.
Squeaking and Survivorship
Ten-year survivorship free from all-cause revision was the same in patients who reported squeaking and those who did not (91% [95% CI 74 to 97] versus 90% [95% CI 71 to 96]; p = 0.69). There were nine revisions in this cohort, although two revisions for squeaking were excluded because they occurred in the second THA of bilateral hip replacement patients. Seven revisions were included for survivorship analysis; four of seven cited squeaking as the indication for revision. The four revisions for squeaking occurred between 2 months and 10 years after the index operation. One patient noted squeaking within 1 month of index surgery and was also diagnosed with acetabular component malposition (excess anteversion). The acetabular component was revised for squeaking and malposition; stripe wear was noted at the revision procedure. Ceramic-on-ceramic components were reimplanted in this young, active patient and the squeaking was attributed to the cup malposition. A patient who had bilateral THA noted squeaking 2 months after initial surgery and underwent acetabular liner exchange to a polyethylene component 2 years after index operation. Both THAs in this patient were revised for squeaking. A third patient developed squeaking THA more than 10 years after index surgery, and underwent head and polyethylene liner exchange. Stripe wear on the femoral head was identified at the revision. A fourth patient with bilateral squeaking CoC THA underwent revision to a metal on polyethylene bearing for squeaking at an outside institution 6 years after initial surgery. In the squeaking group, all the identified revisions cited squeaking as the primary indication. At minimum 1-year follow-up, there were no documented cases of revision, instability, or deep infection among these patients.
There were three revisions in the nonsqueaking group. One was for acetabular component malposition and iliopsoas impingement; the acetabular component anteversion was increased and the bearing was changed to polyethylene. Another patient underwent a head liner exchange and heterotopic ossification excision at an outside institution. Finally, a nonsqueaking acetabular component revision was revised for impingement and remained a CoC bearing.
Squeaking and Outcomes Scores
Patient-reported outcome scores (HOOS JR) were the same in those who reported squeaking versus nonsqueaking THA (3 ± 3 versus 3 ± 5; p = 0.59).
Ceramic-on-ceramic hip arthroplasty has the potential to provide long-term function with excellent wear rates. However, these bearing surfaces carry unique complications such as squeaking, which may negatively affect survivorship. Squeaking has been well documented over short and mid-term follow-up but the reported proportion of patients who report it varies widely. Study designs that capture only revisions for squeaking may underestimate the true frequency of this phenomenon as patients may find painless squeaking a nuisance but not undergo revision surgery. The goal of the current study was to identify the long-term frequency with which patients report squeaking, determine its association on survivorship, and assess whether it was associated with patient-reported outcomes of CoC THA. Given that the cause is not yet known and many etiologies have been described, we also studied the association between patient and implant variables that may contribute to squeaking.
The main limitation of this study was 78% follow-up at mean of 14 years. In general, the health status of the missing—that is, the remaining 22% of patients—is believed to be inferior to those who were successfully contacted . This suggests that our study may underestimate both the proportion of patients who experience squeaking and who have undergone revision with this THA design.
The small population in this study is at risk for data fragility in which a small number of events may change the direction of the observed effect. As such, we excluded three third-generation CoC DePuy S-ROM stems paired with a Duraloc cup (DePuy-Synthes) for analysis due to the disproportionately small size of this group. Although there are larger studies of squeaking CoC THA, the current study has the advantage of long-term follow-up at a mean of 14 years. Consistent with prior studies, we also found the TMZF stem to be associated with an increased proportion of squeaking compared with other stems from the same manufacturer. Retrospective designs often are limited by selection bias. The indications for CoC bearings in this cohort were active, young patients younger than 50 years of age (mean age 44 years), and these represented 23% of THAs performed during this time period. These indications were not universally applied as some older patients also received CoC bearings during this time period. We believe this did not likely significantly affect our conclusions these CoC THA patients were physiologically young, and no age difference was found between squeaking and nonsqueaking groups.
The component position was measured on the 6-week postoperative radiographs but not again at most recent follow-up as the study design was based on a mailed patient survey and prior studies have already been completed examining the relationship between squeaking and component position [9, 17, 24]. Prior studies have associated larger femoral head size with squeaking [4, 22]. Our study found no differences in head size between squeaking and nonsqueaking groups but was underpowered to evaluate this association.
The survey tool was generated by the investigators and is not a validated instrument. The survey was written to avoid pushing respondents to certain answers and was modeled from prior studies on this topic [9, 21, 25]. We felt that patients were reliable in identifying squeaking from other noises as an easily distinguishable high-pitched sound. Lastly, patient-reported outcomes (HOOS JR) were collected only at the latest follow-up. Without baseline scores, no conclusions could be drawn about the effectiveness of CoC THA in this cohort. However, it was useful to illustrate that no difference existed at long-term follow-up between the squeaking and nonsqueaking groups.
Proportion of Patients who Reported Squeaking
We found that 53% of patients in this series reported squeaking from their CoC THA at a mean follow-up duration of 14 years; this is higher than previously reported (two studies found the proportion of patients who reported this symptom were 10.7% and 35.6% [9, 21]). Our findings suggest squeaking can be a late complication occurring years after index surgery. The proportion of squeaking with CoC THA is likely underestimated by earlier studies limited by short-term follow-up [1, 4, 7, 10, 12, 21]. Prior studies that captured revisions for squeaking or patient-initiated reports of squeaking also may underestimate the frequency [2, 5, 15]. The current study directly queried patients on the presence of squeaking, which may explain the higher frequency of squeaking in our population. Although our study examined an earlier generation of ceramic bearing components, we showed that the onset of squeaking CoC THA often occurs many years after index surgery, which may have implications regarding future studies examining long-term frequency of this complication in current generation ceramic components as well.
Factors Associated with Squeaking
Between the patient, radiographic, and implant variables studied, only the stem type differed between squeaking and nonsqueaking groups. Although there was not a uniform distribution of the implant types used, we found that in our cohort squeaking was more common with the TMZF stem (Stryker) compared with the SecurFit stem (Stryker). The difference is likely multifactorial, but other authors have suggested the Accolade TMZF stem (Stryker) metallurgy and trunnion flexural rigidity may contribute to squeaking. Restrepo et al.  found a higher frequency of squeaking with use of a TMZF stem compared with a traditional titanium-aluminum-vanadium alloy, theorizing that resonant frequencies may be more easily transmitted based on the differing modulus of elasticity. A similar retrospective cohort reported that 35% of patients experienced squeaking CoC THA with use of Trident (Stryker) acetabular cups paired with Accolade TMZF (Stryker) femoral stems . Another series found 21% of patients reported squeaking using the recalled ABG II stem (Stryker) which has a modular Co-Cr neck with a V40 taper and the body is also made of TMZF alloy . Coupled with these prior studies, we believe our data supports avoiding the use of the Accolade TMZF stem (Stryker) with CoC bearings to reduce the squeaking risk.
Squeaking and Survivorship
The 10-year survivorship free from all-cause revision in this cohort of young patients was lower than expected based on previous studies [1, 11, 14]. Although survivorship was the same among squeaking and nonsqueaking CoC hips in this small series, a larger cohort or improved follow-up may have found an association between squeaking CoC THA and lower survivorship. Additionally, most revisions (4 of 7) in this cohort were for squeaking. Even though most patients did not report that squeaking negatively affected their quality of life, it was also the most common indication for revision in this cohort. This suggests that the negative effects of squeaking are widely variable; for some patients it is only a mild nuisance, but others may request a revision due to these symptoms. Surgeons should therefore specifically inform patients of this potential complication, and be selective in those they indicate for CoC THA.
Squeaking and Outcomes Scores
Patient-reported outcome scores (HOOS JR) were identical between the squeaking and nonsqueaking cohorts. Although no conclusion can be drawn regarding effectiveness of CoC THA based on lack of preoperative data, the values collected were typical of hip arthroplasty in young patients [6, 20].
We found that CoC THA squeaking was more common than previously reported and may occur years after the index procedure. Although not typically associated with pain or poor patient-reported outcomes, it is an indication for revision and may affect survivorship. Certain femoral components such as the Accolade TMZF stem (Stryker) have higher risk of squeaking with ceramic bearings although the exact reason is unknown. It is our belief that despite the known advantages of CoC bearings, surgeons should appropriately counsel young patients on the potential risks of their use include squeaking.
The authors would like to thank Keith Holley MD, Michael Fraser MD, Lance Leclere MD, and John Martell MD, for their previous contributions to this study.
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