Squeaking in total hip replacement: no cause for concern

Squeaking in ceramic-on-ceramic hips: No evidence of contribution from the trunnion morse taper

Squeaking in ceramic-on-ceramic (CoC) total hip arthroplasty (THA) was investigated with an acoustic monitoring device to distinguish between squeaking emanating from the trunnion morse taper (TMT) connection versus the articular surface. 82 patients with implant problems scheduled for revision were selected and acoustic emissions (AE) with simple movements monitored. Five of these patients with CoC implants underwent surgery and their retrieved implant components were analyzed in vitro. In vivo recordings of all 82 patients found audible squeaks produce frequency content across the entire 0-50 kHz spectrum. Of the five CoC implants the in vivo peak frequency range of flexion/extension motions was 0.8 kHz and comparable to the range of in vitro testing (0.2 kHz). In vitro TMT connection motions were very large comparatively, producing a higher average peak frequency range of 22.5 kHz. All retrieved implants showed evidence of wear at the TMT connection. These findings suggest, the TMT connection does not directly cause audible squeaking. Wear occurring at this junction may contribute to debris which disrupt lubrication, increase friction, and produce noise. This observation supports current evidence suggesting that squeaking is from the bearing surface. Our findings are the first to demonstrate that in CoC THA the recordable noise of a hip squeak does not originate nor have contribution from the TMT connection. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1793-1798, 2017.

Hip Squeaking after Ceramic-on-ceramic Total Hip Arthroplasty

Objective:

The present study aimed to review the characteristics and influencing factors of squeaking after ceramic-on-ceramic (CoC) total hip arthroplasty (THA) and to analyze the possible mechanisms of the audible noise.

Data Sources:

The data analyzed in this review were based on articles from PubMed and Web of Science.

Study Selection:

The articles selected for review were original articles and reviews found based on the following search terms: “total hip arthroplasty”, “ceramic-on-ceramic”, “hip squeaking”, and “hip noise.”

Results:

The mechanism of the squeaking remains unknown. The possible explanations included stripe wear, edge loading, a third body, fracture of the ceramic liner, and resonance of the prosthesis components. Squeaking occurrence is influenced by patient, surgical, and implant factors.

Conclusions:

Most studies indicated that squeaking after CoC THA was the consequence of increasing wear or impingement, caused by prosthesis design, patient characteristics, or surgical factors. However, as conflicts exist among different articles, the major reasons for the squeaking remain to be identified.

Meta-analysis of the Incidence and Risk Factors for Squeaking after Primary Ceramic-on-ceramic Total Hip Arthroplasty in Asian Patients

Purpose

The purpose of this study was to assess the squeaking incidence and risk factors after primary ceramic-on-ceramic total hip arthroplasty (THA) in Asian patients using meta-analysis.

Materials and Methods

We performed a meta-analysis of published data on the squeaking incidence and risk factors from 2000 to 2013. Eight studies in Asians were analyzed for both squeaking incidence and risk factors and 25 studies in Western patients were analyzed for squeaking incidence. The data collected were: patient factors, surgical factors and implantation factors.

Results

The overall incidence of hip squeaking was 2.7% in Asians and 3.1% in Westerners. This difference was not statistically significant. The only significant risk factor was an increase in the acetabular cup abduction angle. Of the factors, the cup abduction angle was the only significant risk factor for the occurrence rate of squeaking, and the occurrence rate tended to increase with increasing angle.

Conclusion

The incidence of squeaking in Asians after primary ceramic-on-ceramic THA is 2.7% and is similar to that in Westerners. The increased cup abduction angle is associated with squeaking; therefore, surgeons should be careful not to implant the cup at a too steep abduction angle.

An estimation of the incidence of squeaking and revision surgery for squeaking in ceramic-on-ceramic total hip replacement: a meta-analysis and report from the Australian Orthopaedic Association National Joint Registry

Squeaking arising from a ceramic-on-ceramic (CoC) total hip replacement (THR) may cause patient concern and in some cases causes patients to seek revision surgery. We performed a meta-analysis to determine the incidence of squeaking and the incidence of revision surgery for squeaking. A total of 43 studies including 16,828 CoC THR that reported squeaking, or revision for squeaking, were entered into the analysis. The incidence of squeaking was 4.2% and the incidence of revision for squeaking was 0.2%. The incidence of squeaking in patients receiving the Accolade femoral stem was 8.3%, and the incidence of revision for squeaking in these patients was 1.3%.

The influence of stem design on critical squeaking friction with ceramic bearings

Ceramic-on-ceramic hip joints have been reported to squeak, a phenomenon that may occur in compromised lubrication conditions. One factor related to the incidence of in vivo squeaking is the stem design. However, it has not yet been possible to relate stem design to squeaking in deteriorating lubrication conditions. The purpose of this study was to determine critical friction factors for different stem designs. A hip simulator was used to measure the friction factor of a ceramic bearing with different stem designs and gradually deteriorating lubrication represented by evaporation of a volatile fluid lubricant. The critical squeaking friction factor was measured at the onset of squeaking for each stem. Critical friction was higher for the long cobalt chrome (0.32 ± 0.02) and short titanium stems (0.39 ± 0.02) in comparison with a long titanium stem (0.29 ± 0.02). The onset of squeaking occurred at a friction factor lower than that measured for dry conditions, in which squeaking is usually investigated experimentally. The results suggest that shorter or heavier stems might limit the possibility of squeaking as lubrication deteriorates. The method developed can be used to investigate the influence of design parameters on squeaking probability.

Can squeaking with ceramic-on-ceramic hip articulations in total hip arthroplasty be avoided?

Squeaking is a recognized complication of total hip arthroplasty with ceramic on ceramic bearings but the etiology has not been well identified. We evaluated 183 hips in 148 patients who had undergone ceramic-on-ceramic noncemented total hip arthroplasties at one center between 1997-2007 by standardized telephone interviews and radiographic review. Audible squeaking was reported from 22 hips (12% of 183) of 19 patients. Prevalence of squeaking was associated with younger age; obesity; lateralized cup position; use of beta titanium alloy femoral components and shortened head length options; and higher reported activity level, greater pain, and decreased satisfaction at the time of the interview. Squeaking was described as having little personal significance by most patients. Squeaking might be preventable in part through medialization of the acetabular cup and avoidance of the use of shortened femoral necks.

The natural history of ceramic-on-ceramic prosthetic hip squeak and its impact on patients

BACKGROUND

Ceramic-on-ceramic (CoC) total hip arthroplasty (THA) has been scrutinised for a high incidence of post-operative squeak. The psychological and social consequences, and subsequent request for revision surgery are not well documented.

METHODS

Seventy consecutive primary CoC THA operated on by a single surgeon at a single institution were enroled and followed for an average 7.1 years. Information was obtained from routine post-operative review, medical records, mailed questionnaire and periodic phone interview.

RESULTS

Of 70 THA, 69 were available for follow-up. Seventeen (24.6 %) reported at least one instance of squeak, occurring on average 34.2 months post-operatively. Five (7.5 %) recalled being warned preoperatively of squeak as a potential complication. Six reported infrequent squeak and 11 frequent squeak. Ten were concerned, reporting embarrassment, harassment and anxiety regarding the longevity of their THA. One patient was planning revision surgery.

DISCUSSION

This study demonstrates the highest published prevalence of squeaking CoC THA and highlights the importance of warning patients of this potential complication.

Retrieval analysis of squeaking ceramic implants: are there related specific features?

INTRODUCTION

Ceramic-on-ceramic total hip arthroplasty is routinely used for young and active patients with end stage of hip osteoarthritis. However, squeaking noise is a recently identified problem with such bearing surface. Many in vivo and in vitro studies have been conducted trying to find the potential causes of this phenomenon. However, we are not aware of any study analyzing retrieved ceramic implants for squeaking.

HYPOTHESIS

Our primary hypothesis was that the surface analysis of retrieved ceramic implants with squeaking would present interesting deteriorations that could explain the squeaking noise.

MATERIALS AND METHODS

Nine retrieved squeaking implants from ceramic-on-ceramic total hip arthroplasty that were retrieved for various reasons (two exclusively for squeaking, four for recurrent dislocation, one for aseptic loosening and two for instability) were analyzed. Implant positioning was calculated, macroscopic damages were noticed and microscopic roughness was analyzed. The retrieved implants were then tested on a hip simulator reproducing flexion/extension motions in several situations in lubricated and non-lubricated conditions in order to reproduce squeaking.

RESULTS

Five cups were considered with borderline insufficient anteversion. Gross impingement damage was visible on seven implants. All the retrieved heads had visible metal transfer on their surface. Eight implants had visible stripe wear. Microscopic analysis showed roughness higher than six microns on the retrieved heads. Squeaking was reproduced in vitro in dry conditions. In lubricated conditions, squeaking did not occur for the retrieved hips.

DISCUSSION

This retrieval analysis suggests that problems of cup orientation and design which can lead to impingement can generate lubrication problems because of metal transfer plus/minus stripe wear which is a common theme in ceramic-on-ceramic bearings that squeak.

Squeaking in third- and fourth-generation ceramic-on-ceramic total hip arthroplasty: meta-analysis and systematic review

Postoperative squeaking in ceramic-on-ceramic total hip arthroplasty is a recently emerging phenomenon. We performed a meta-analysis of published data to examine patient and procedural risk factors. Twelve studies (6137 patients, total) were analyzed, with 150 patients (2.4%) complaining of squeaking. The only significant patient risk factor was increasing body mass index (P = .03, n = 2957). There was no significance found with patient age, sex, height, weight, or procedural laterality for squeak incidence. For implant type, the presence of a Stryker Accolade femoral stem (beta-titanium; Stryker Orthopedics, Mahwah, NJ) was significantly found to increase squeak (P < .0001, n = 4654). The presence of a raised metallic lip on the acetabular component was not found to be associated with squeak. Acetabular cup position was also not found to have a significant bearing on the incidence of squeaking.

Spectral characterization of squeaking in ceramic-on-ceramic total hip arthroplasty: comparison of in vitro and in vivo values

Squeaking is a cause for concern in total hip arthroplasty (THA). However, the definition of this sound remains vague. Our goals were to characterize spectrally the squeaking in vitro under lubricated conditions and to compare the in vitro frequencies to in vivo frequencies. Four patients, who presented with a squeaking after ceramic-on-ceramic THA were investigated. In addition, 3 alumina ceramic 32 mm diameter components were tested in vitro under edge loading conditions using a friction simulator. Tests were conducted under lubricated conditions without and with the addition of a third body alumina particle. In vitro, no squeaking occurred under edge loading conditions. However, with the addition of a third body particle in the contact region, squeaking was obtained; the dominant frequency was 2.6 kHz. In vivo, the main recorded sound frequencies were: 2.3, 2.24, and 2.46 kHz for squeakers during walking and 1.45 kHz for a squeaker rising from a bent position. The in vivo recordings had a dominant frequency similar to, but slightly lower than, the in vitro values. Two types of squeaking were found in vivo and characterized spectrally. The rising squeaker had intermittent squeaking corresponding to a lower fundamental frequency compared to the walking squeakers. This finding suggests two different mechanism of squeaking.

State of the art in hard-on-hard bearings: how did we get here and what have we achieved?

Total hip arthroplasty has shown excellent results in decreasing pain and improving function in patients with degenerative disease of the hip. Improvements in prosthetic materials, designs and implant fixation have now resulted in wear of the bearing surface being the limitation of this technology, and a number of hard-on-hard couples have been introduced to address this concern. The purpose of this article is to review the origins, development, survival rates and potential advantages and disadvantages of the following hard-on-hard bearings for total hip arthroplasty: metal-on-metal standard total hip arthroplasty; metal-on-metal hip resurfacing arthroplasty, ceramic-on-ceramic total hip arthroplasty; and ceramic-on-metal bearings. Improvements in the manufacturing of metal-on-metal bearings over the past 50 years have resulted in implants that provide low wear rates and allow for the use of large femoral heads. However, concerns remain regarding elevated serum metal ion levels, potential teratogenic effects and potentially devastating adverse local tissue reactions, whose incidence and pathogenesis remains unclear. Modern total hip resurfacing has shown excellent outcomes over 10 years in the hands of experienced surgeons. Current ceramic-on-ceramic bearings have demonstrated excellent survival with exceptionally low wear rates and virtually no local adverse effects. Concerns remain for insertional chipping, in vivo fracture and the variable incidence of squeaking. Contemporary ceramic-on-metal interfaces are in the early stages of clinical use, with little data reported to date. Hard-on-hard bearings for total hip arthroplasty have improved dramatically over the past 50 years. As bearing designs continue to improve with new and modified materials and improved manufacturing techniques, it is likely that the use of hard-on-hard bearings will continue to increase, especially in young and active patients.

Ceramic-on-ceramic hip outcome at a 5- to 10-year interval: has it lived up to its expectations?

This study reports revision and complication rates of a single cementless double-wedged tapered stem with an alumina-alumina bearing over 10 years since the beginning of premarket clinical trials. Of 930 hips (848 patients) implanted by 9 surgeons, there were 19 revisions at mean follow-up of 5.9 years compared to 10 revisions in the 123 hips implanted with the polyethylene control group at mean 7.8 years. The ongoing safety of alumina-alumina bearings is demonstrated through excellent (96.8%) survivorship at 10 years. Twenty-one patients reported 23 incidences of noise described as clicking, squeaking, popping, or creaking. Eight patients with 9 hips described the noise as squeaking, most occurring rarely and only 1 occurring frequently in a patient subsequently revised for a reason aside from the squeaking.

Influence of acetabular cup rim design on the contact stress during edge loading in ceramic-on-ceramic hip prostheses

The purpose of the study was to investigate the contact stresses in 3 different acetabular cup rim designs (new, worn, chamfer) during edge loading, after microseparation of ceramic on ceramic hip prostheses. A 3-dimensional finite element analysis was conducted for a 28-mm diameter alumina ceramic bearing with a radial clearance of 40 μm using a normal load of 2500 N under edge loading. At a separation distance of 250 μm, the maximum tensile stress in the "new" design was of similar magnitude to the flexural strength of the alumina material that supports the localized breakdown (stripe wear) of the acetabular cup surface observed clinically. Introducing a 2.5-mm radius chamfer should reduce the maximum tensile stress in the region of 60%.

In vitro investigation of friction under edge-loading conditions for ceramic-on-ceramic total hip prosthesis

Edge-loading generates higher wear rates in ceramic-on-ceramic total hip prosthesis (THP). To investigate the friction coefficient (FC) in these conditions, three alumina ceramic (Biolox Forte) 32 mm-diameter components were tested using a hip friction simulator. The cup was positioned with a 75 degrees abduction angle to achieve edge-loading conditions. The motion was first applied along the edge and then across the edge of the cup. First, tests were conducted under lubricated conditions with 25% bovine serum. Next, to simulate an extremely high contact pressure, the tests were run with the addition of a third body alumina ceramic chip inserted between the edge of the cup and the head. Engineering blue was used to analyze the contact area. Reference values were determined using a 0 degrees cup abduction angle. Edge loading was achieved. The FC increased by three- to sixfold when the motion was applied along the edge, and by 70% when the motion was applied across the edge. However, the FC value was still low (about 0.1), which is similar to metal-on-metal THP. With the third body alumina ceramic particle inserted, the FC was 26 times higher than in the ideal conditions and intermittent squeaking occurred. High cup abduction angles may generate edge-loading and an increase in the friction coefficient for ceramic THP.