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The Journal of Arthroplasty Vol. 27 No. 6 2012

Hip Squeaking

A 10-Year Follow-Up Study

Christophe Chevillotte, MD,*y Vincent Pibarot, MD,* Jean-Paul Carret, MD,*yJacques Bejui-Hugues, MD,yz and Olivier Guyen, MD, PhD*y

Abstract: The aim of the study was to analyze the incidence of squeaking with ceramic-on-ceramic total hip arthroplasty (THA) after 10 years of follow-up and the potential complicationsthat could occur related to this phenomenon. One hundred THAs implanted between November1999 and December 2000 were evaluated. Incidence of squeaking was investigated clinically witha questionnaire. Implant positioning was analyzed on x-rays and computer tomography. Of the100 THAs, 5 patients presented with squeaking. All of them were active, sporty, and heavy men.Functional scores were comparable with nonsqueaking patients. There was no malpositioning onthe x-ray analysis, no wear, and no loosening. We could not demonstrate any relation betweensqueaking and ceramic fracture. Squeaking noise appeared at a mean of 66 months postsurgery. Itappears to be an isolated phenomenon without any consequences at 10-year follow-up.Keywords: hip, ceramic, squeaking, total hip arthroplasty, surface bearing.© 2012 Elsevier Inc. All rights reserved.

Ceramic-on-ceramic total hip arthroplasty (THA) hasbeen developed in the 1970s by the French orthopedicsurgeon Pierre Boutin [1,2]. Since the beginning ofusing this material, many changes have been observedto improve results. Problems of loosening have de-creased using a metal back [3]; fracture risk have beendramatically reduced with the use of the third-genera-tion of alumina [4-6]. However, a new problem iscurrently focused for this surface bearing: squeakingnoise. During the past 5 years, this problem has beenhighlighted in the literature, with numerous in vivo[7-19] or in vitro [20-25] studies concerning squeakingwith ceramic on ceramic, to identify the cause for thisproblem. The following potential contributing factors arecurrently discussed: problem of lubrication with the role

e *Department of Orthopedic Surgery, Pavillon T, Hôpital Edouardyon Cedex 03, France; yLaboratoire de Biomécanique des Chocs,ETS URMT 9406, Université Claude Bernard, Lyon, France; and

a F. Faggiana, Latina, Italy.tted May 7, 2011; accepted November 27, 2011.nflict of interest statement associated with this article can bedoi:10.1016/j.arth.2011.11.024.barot, Carret, Bejui-Hugues, and Guyen receive royaltiesplitude company. Ethical committee approval was notfor this study in our country.t requests: Christophe Chevillotte, MD, Pavillon T, HôpitalHerriot, 5 place d' Arsonval, 69437 Lyon Cedex 03, France.2 Elsevier Inc. All rights reserved.403/2706-0029$36.00/0.1016/j.arth.2011.11.024

100

of a third body [20], presence of “stripe wear” on theceramic head [25], impingement between the stem andthe cup related to poor design [8] or to malpositioning ofthe implants [19], poor offset [13], vibration of the stem[21], or microfractures [6]. However, we are not awareof any study analyzing squeaking at long-term follow-up. In addition, the influence of squeaking on thepatient and the implant remains unknown. The aim ofthe study was to analyze the incidence of squeaking, toidentify circumstances for generating squeaking, andconsequences for the patient and the implants at10 years of follow-up.

Material and MethodsWe analyzed at latest follow-up a continuous series of

100 primary ceramic-on-ceramic cementless THA, per-formed at our institution between November 1999 andDecember 2000. The indications for the use of this implantwere young (mean age, 52.3 years [standard deviation,12.7]) and active patients. Relative contraindications forthe use of this implant were elderly low-demand patients.The 100 THAs were performed on 92 patients. At latestfollow-up, 7 patients haddiedof unrelated causes,withnoreported squeaking problem. Four patients were lost offollow-up 2 years after the index procedure. All of themwere known to have a well-functioning and nonsqueak-ing THA at last review. There were 81 patients (89 THAs)available for the study at a minimum follow-up of115months (mean,120.5months; range, 115-135months).

8

Table 1. Underlying Diagnoses at the Time of Surgery

Underlying Diagnosis No. of Patients

Primary osteoarthritis 60Osteonecrosis 16Developmental dysplasia 13Post traumatic arthritis 5Inflammatory arthritis 4Femoral neck fracture 1Hip fusion 1Total 100

Hip Squeaking � Chevillotte et al 1009

The study group included 50 men and 31 women. Themost common reason for THAwas primary osteoarthritis(Table 1). Demographic data were reported from themedical records.The single design of uncemented implants used

consists of an 80-μm hydroxyapatite plasma-sprayedpress fit hemispherical acetabular titanium shell (Hori-zon; Amplitude, Porte du grand Lyon, Neyron, France),with a third-generation ceramic liner (Biolox Forte;CeramTec, Plochingen, Germany) (Fig. 1). In such adesign, the liner fits the shell using a 18° morse taper.A single design of uncemented femoral component

was also used for all the patients: this stem was made oftitanium and 80-μm fully hydroxyapatite coated, with a137° neck-shaft angle, a 10/12 morse taper with 5°42′angle (Integrale; Amplitude) (Fig. 2).In all hips, a 28-mm third-generation alumina head

was used (Biolox Forte; CeramTec). A short neckfemoral head component was used in 12 hips, a mediumneck femoral head component in 68 hips, and a longneck femoral head component in 9 hips.Component clearance was between 20 and 80 μm.

Minimal ceramic thickness was 6.5 mm at the bottomand 5.8 mm on the edge.The index THAs were performed under the supervi-

sion of 2 senior orthopedic surgeons (J. P. C., J. B. H.) at

Fig. 1. Acetabular titanium shell (Horizon; Amplitude), with

our institution. A posterior approach was used in34 cases, and a Hardinge anterolateral approach in 55cases, at the surgeon's discretion. Postoperative rehabil-itation was standardized. Patients were mobilized thefollowing day after surgery. Patients were instructed onrange of motion and strengthening exercises, and alltherapy was supervised. Full weight bearing wasallowed at day 1, starting with the use of a walker andthen moving to a cane when able to. All patients wereable to achieve stair climbing before hospital discharge.All the patients had been clinically and radio-

graphically evaluated preoperatively and postopera-tively at 6 weeks, 3 months, 6 months, and everyyear after surgery.Assessment of the clinical results was performed

using Harris hip score and Postel–Merle d'Aubignéscore. Patient activity at latest follow-up was evaluatedusing the University of California Los Angeles (UCLA)score. Changes from the preoperative clinical status tothe latest clinical follow-up were evaluated for all thepatients using the Wilcoxon signed rank test.Radiographic assessment was performed using stan-

dard anteroposterior and lateral radiographs of theinvolved joint. X-rays were reviewed by 2 independentsenior surgeons to assess the position of the prosthesisand to look for wear, osteolysis, signs of implantloosening, or fractures. Wear measurement was donemanually using duoradiographic measurement as de-scribed by Charnley [26]. It consisted of comparing thethickness of the ceramic liner in the most recentradiograph with the thickness in the postoperative filmat the same point.Femoral components were assessed for subsidence,

and the femur was divided into 7 zones as described byGruen et al [27] to assess radiolucent lines andosteolysis. Acetabular components were evaluated ineach of the 3 zones defined by DeLee and Charnley [28]to evaluate the location of radiolucent lines.

a third-generation ceramic liner (Biolox Forte; CeramTec).

Table 2. Squeaking Questionnaire With Results for the 5Squeaking Patients

Question Squeaking Patients (5)

Do you feel noise in your hip? Yes (5/5)Has it been heard by other people? Yes (5/5)What king of noise? Squeaking (5/5)In what situation does it appear? Rising from a chair (1)

Bending (2)Casual walking (2)

What is its frequency? Daily (2)Every week (1)Occasionally (2)

What is the time of occurrence sinceyour hip surgery?

66 mo (4-85)

Is it stable over time? Yes (5/5)Do you feel pain or discomfort

associated with squeaking noise?No (5/5)

Did you have other problems withyour hip prosthesis?

Dislocation 8 mo aftersurgery (1)Instability (1)Leg lengthdiscrepancy N1 cm (1)

Finally, is squeaking noise ahindrance for daily living?

Moderate hindrance (2)

Not a real problem (3)

Fig. 2. Uncemented femoral component (Integrale; Amplitude).

1010 The Journal of Arthroplasty Vol. 27 No. 6 June 2012

When a patient reported squeaking, a computertomographic evaluation of the involved joint wasperformed to assess the position of the prosthesis ofacetabular cup anteversion and inclination.To determine the causes and consequences of squeak-

ing, patients were evaluated using a questionnaireperformed during latest follow-up or by telephoneafter the last review. This questionnaire, recentlydeveloped by our orthopedic department, consisted of10 open questions, as follows:“Do you feel noise in your hip?” If a patient answered

“yes,” he or she was asked the 9 other questions: “Hasthis noise already been heard by people around you?”“What kind of noise do you hear?” “In what situationsdoes it appear?” “What is its frequency?” “What is thetime of occurrence since your hip surgery?” “Is it stableover time?” “Do you feel pain or discomfort associatedwith squeaking noise?” “Did you have other problemswith your hip prosthesis?” “Finally, do you thinksqueaking noise is a hindrance for daily living?”Questionnaire for the squeaking patients is reportedin Table 2.We used χ2 test to compare categorical variables

(Gender, side of surgery, diagnosis, approach, cupsize, neck length, femoral stem size) betweenpatients without and with squeaking, and indepen-dent t tests to compare continuous variables (age,height, weight, body mass index, Harris hip score

[29], Postel–Merle d'Aubigné score [30], UCLAscore [31].

ResultsSix patients (6 THAs) reported an audible noise in their

THA (6.7%) (Table 3). Specifically, 5 hips squeaked (5.6%)and 1 hip clicked (1.1%). There were no cases of grind orpop. No patients were able to reproduce the squeakingnoise in clinical setting. The squeaking noise appeared at amean of 66 months (4 to 85 months) postsurgery. Twopatients complained of squeaking daily, 1 patient everyweek, and 2 patients occasionally. Squeaking was consid-ered as a moderate hindrance in daily living for the2 patients with daily squeaking problem. For the 3 otherpatients who experienced squeaking, this phenomenonwas only mentioned because of the questionnaire but notconsidered as a real problem. As a result, only 2.2% of thispopulation had a real squeaking problem.Once squeaking occurred, it remained stable in time

concerning frequency and intensity. Activities thatreproduced squeaking were rising from a sitting chairfor 1 patient, bending for 2 patients, and casual walkingfor 2 patients. No patient complained of pain during thesqueak (Table 2).Gender, height, and weight were associated with

squeaking (Table 3). Squeaking was higher in the hipsof heavier (P b .0008) and taller males (P b .0001). Ageand body mass index were not associated with squeak-ing. The 5 squeaking patients had an elevated UCLAactivity score at latest follow-up (8-10). There was nodifference between squeaking and nonsqueaking pa-tients concerning Harris hip score and Postel–Merled'Aubigné score preoperatively and postoperatively. The

Table 3. Patients and Implants Demographics: Total HipArthroplasty With and Without Squeaking

Variable

Total HipArthroplasty

WithSqueaking

Total HipArthroplastyWithoutSqueaking P

n 5 84Age 51 52.3 .85GenderMale 5 51 .01Female 0 33 .01

Weight, kg 100 75 .0008Height, cm 185 169 b.0001Body mass index, kg/m2 28,7 26 .19Neck length Medium Medium .24Cup size 58 52 .0004Stem size 6 3 .0002University of California

Los Angeles score8.5 6.9 .04

Harris hipscore preoperative

43 41.2 .48

Harris hip score atlatest follow-up

96.5 96.1 .30

Postel–Merle d'AubignéScore preoperative

8 7.9 .74

Postel–Merle d'AubignéScore at latest follow-up

17 17.2 .16

Surgical approachPosterior 2 33 .97Hardinge 3 62 .97

P b .05.

Hip Squeaking � Chevillotte et al 1011

mean Harris hip score improved from 43 points (range,25-55 points) preoperatively to 96.5 points (range, 90-100 points) at the time of latest follow-up for thesqueaking group, and from 41.2 points (range, 20-60 points) preoperatively to 96.1 (range, 58-100 points)postoperatively for the nonsqueaking group. The meanPostel–Merle d'Aubigné score improved from 8 points(range, 5-11 points) preoperatively to 17 points (range,16-18 points) at the time of latest follow-up for thesqueaking group, and from 7.9 points (range, 3-13 points) preoperatively to 17.2 (range, 11-18 points)postoperatively for the nonsqueaking group. There wasalso no difference between the 2 groups for postoper-ative range of motion at latest follow-up.Surgical approach was not associated with squeak-

ing. Squeaking occurred in a higher percentage (P b.002) of patients with bigger acetabular and femoralcomponent (Table 3). Neck length was not associatedwith squeaking.

Table 4. Results of Implants Position

Parameter

NonsqueakingPatients x-rayMeasurements

SquePatientMeasur

Cup anteversion 19.6 (n = 84) 20.3 (nCup inclination Not applicable Not app

Radiologic analysis revealed no wear and no evidenceof osteolysis in both groups. No cup and/or stemloosening was found for the squeaking group. For thenonsqueaking group, one case of cup loosening wasfound at latest follow-up and a cup revision waspending. For the squeaking group, implant positioningmeasured using computed tomographic scan wassatisfactory: all the cups were measured in the safezone as described by Lewinneck et al [32] (Table 4).Complications in the squeaking group included

1 case of dislocation at 8 months after surgery(squeaking occurred 70 months after this complica-tion), 1 patient complaining of instability, and 1 leglength discrepancy greater than 1 cm. There was noceramic head fracture and no pain associated withsqueaking. None of the squeaking patients expected arevision surgery for this problem.

DiscussionIncidence of noise with ceramic-on-ceramic THA has

been reported in the literature varying from less than1% to 20.9%, including grinding, popping, andsqueaking [16-19,33-36]. However, all of those studieshave a short follow-up—shorter than 5 years[17-19,34,35]. The aim of this study was to analyzethe incidence and consequences of squeaking with alonger follow-up. At 10 years of follow-up, theincidence of patients complaining for squeaking is2.2%. This result is in accordance with shorterfollow-up studies [7,8,17,19,35].The method used to detect squeaking may explain the

high variability of the reported incidence. Most of thepatients who experienced occasional squeaking do notmention this phenomenon unless they are questionedfor. In the present study, all patients had beenquestioned about potential squeaking. None of thepatients with squeaking spontaneously complainedabout this noise.Regarding the demographic specificities of patients

complaining of squeaking, we observed that men withhigh weight and height and high level of activity aremore likely to experience squeaking. Squeakingoccurred more frequently for men than for women.These results are in agreement with those of Walter[19] and Poggie [37], who observed squeaking to bemore frequent for “heavier, taller and younger” and“heavier” men.

akings X-rayements P

Squeaking PatientsComputed TomographicScan Measurements

= 5) .38 21.2licable 43.6

1012 The Journal of Arthroplasty Vol. 27 No. 6 June 2012

Moreover, all the squeaking implants were bigger thanfor the patients who did not experience squeaking. Thisis related to the previous statement as larger implants areused in taller patients.Recent studies tend to prove that squeaking noise

occurs more frequently with bigger head diameter [11].However, we were not able to point out this fact as28 mm was the only head diameter available at the timeof surgery in our series.Walter et al [19] found a significant relationship

between squeaking and malpositioning. Among thesqueaking hips, we did not find any malpositioningbased on the Lewinneck safe zone. This result is inaccordance with those of Restrepo [17], Keurentjes [18],and Stanat recent meta analysis [38], who did not findany significant effect of implant position on theincidence of squeaking. However, in our study, ourconclusion on this topic needs to be moderated: first, wedid not have any control group for the computertomographic evaluation. Second, the safe zone asdescribed by Lewinneck remains controversial.Wear measurement needs also to be moderated. The

method used was described by Charnley in 1975 tomeasure the rate of wear for polyethylene cup.Moreover, because of the radiographs, the accuracy ofthe measurement cannot be greater than 0.5 mm [26].As a result, wear measurement for ceramic, which isknown to be dramatically smaller than polyethylene,was negative. However, even with this method ofanalysis, we thought that a very excessive wear,potentially caused by squeaking problem, could havebeen found and revealed.All the squeaking patients had a major or minor

complication in their prosthesis history: dislocation,instability, and leg length discrepancy greater than1 cm. All of these complications can lead to impinge-ment generating third body particles, potentially inter-rupting fluid lubrication between ceramic surfaces. Thistheory is supported by recent in vitro studies [20] and byParvizi et al [8] who discussed the role of implant designon impingement leading to squeaking noise. In ourstudy, all the implants were similar, and the ceramicliner was not surrounded by a titanium rim. However,metal particles may have been transferred during thedislocating event in one case, during subluxation inanother case, and during the swing phase because of leglength discrepancy in the other case. As a result, implantdesign is not the only factor leading to squeaking but canemphasize the problem.Nevertheless, after 10 years of follow-up, patients with

squeaking hip did not have any excessive wear, headfracture, cup or stem loosening, abnormal pain, or anylimitation of their activities. Harris hip score and Postel–Merle d'Aubigné score were comparable. Squeaking didnot disappear in the time but remained stable inintensity. There were no new cases after 85 months of

follow-up. Squeaking noise seems to be an isolatedphenomenon with no consequences for the patientregarding functional results and on the implant longev-ity at 10 years of follow-up. Navigation system withimproved implants positioning in order to reduceimpingement and improve range of motion may leadto a decrease of this phenomenon. Such an assumptionneeds to be investigated in future study.

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