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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 Orthopaed...

Article  in  Bone and Joint Journal · February 2014

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 HIP
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
D. H. Owen, ORTHOPAEDIC ASSOCIATION NATIONAL JOINT REGISTRY
N. C. Russell,
P. N. Smith,
W. L. Walter 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
From Trauma and meta-analysis to determine the incidence of squeaking and the incidence of revision surgery
Orthopaedic for squeaking. A total of 43 studies including 16 828 CoC THR that reported squeaking, or
Research Unit, The revision for squeaking, were entered into the analysis. The incidence of squeaking was 4.2%
Canberra Hospital, and the incidence of revision for squeaking was 0.2%. The incidence of squeaking in
Woden, Australia patients receiving the Accolade femoral stem was 8.3%, and the incidence of revision for
squeaking in these patients was 1.3%.
Cite this article: Bone Joint J 2014;96-B:181–7.

D. H. Owen, MBBS, BE/BSc
(Hons/Hons), Orthopaedic
Registrar
P. N. Smith, BMBS, FRACS
(Orth), Orthopaedic Surgeon
Trauma and Orthopaedic
Research Unit, Building 6 Level
1, The Canberra Hospital, PO
Box 11, Woden ACT, 2606, and
Australian National University
Medical School, Level 2, Peter
Baume Building 42, Linnaeus
Way, Canberra, ACT, 0200,
Australia.
N. C. Russell, MBBS, BE
(Hons), Orthopaedic Registrar
Royal Adelaide Hospital,
Department of Orthopaedics
and Trauma, North Terrace,
Adelaide, South Australia,
Australia.
W. L. Walter, MBBS, FRACS
(Orth), FAOrthA, PhD,
Orthopaedic Surgeon
Specialist Orthopaedic Group,
Suite 1.08, Mater Clinic, 3-9
Gillies Street, North Sydney,
New South Wales, 2060,
Australia.
Correspondence should be sent
to Dr D. H. Owen; e-mail:
david.h.owen@gmail.com
©2014 The British Editorial
Society of Bone & Joint
Surgery
doi:10.1302/0301-620X.96B2.
32784 $2.00
Bone Joint J
2014;96-B:181–7.
Received 13 July 2013;
Accepted after revision 22
October 2013
In ceramic-on-ceramic (CoC) total hip replace-
ments (THR) squeak is an unusual phenome-
non that has attracted the interest of the
orthopaedic community, as it represents an
unanticipated complication of THR that has
multiple contributing factors.1
Wear-related failure is the most common
reason for revision in many published series
and joint arthroplasty registries,2-4 and is sig-
nificant for young patients who have long life
expectancies and place high physical demands
on their THRs.5
Currently available bearing materials include
moderate to highly cross-linked polyethylene
with metal, metal-on-ceramic, metal-on-metal or
CoC.6,7 A number of laboratory8-10 and clinical
studies6,7,11-13 have demonstrated superior wear
rates for CoC couplings, although there is a need
for long-term clinical studies to confirm these
observations. Limitations of such bearings
include the risk of fracture of the head and liner,
and squeaking.6,14 Squeaking in CoC bearings
was first reported by Charnley in 1979 15 and has
been sporadically reported in cases of mis-
matched ceramic bearing surfaces16 and bearing
failure. However, it was not until the late 2000s
that squeaking from THR attracted widespread
attention from the media17 and the orthopaedic
community.18-20 This gave rise to a number of
clinical21-25 and laboratory18,26-29 studies aimed
at investigating the incidence and mechanisms of
noise generation in THR. It has been reported
that a squeaking THR may affect the patient’s
quality of life, and in few cases cause them to
undergo revision surgery.22,30,31
We have explored published series by meta-
analysis to determine the incidence of squeaking
and the frequency of revision surgery for squeak-
ing. In addition, data from the Australian Ortho-
paedic Association National Joint Replacement
Registry (AOANJRR) are presented and the pro-
posed mechanisms of squeaking in CoC THR are
reviewed.
Materials and Methods
We used the guidelines for the construction of
a meta-analysis.32,33 On 5 January 2013 we
searched the PubMed database with combina-
tions of the terms ‘hip and squeak’, ‘hip and
squeaking’, ‘hip and ceramic’, ‘hip and noise’,
‘squeak and arthroplasty’, ‘squeaking and
arthroplasty’, ‘arthroplasty and ceramic’, and
finally ‘noise and arthroplasty’. The search
was confined to the English language and
human studies. Citation and internet searches
were performed to include all published series.
In all, 1403 articles were identified for assess-
ment by title and abstract for further evalua-
tion by two of the authors (DHO, NCR).
During this process duplicates, case reports
and review articles were removed. Posters and
conference presentations were not considered.
A total of 116 articles were subsequently
identified which were searched in their entirety
for documentation of noise, squeaking or sound
originating from a CoC THR. Studies were

VOL. 96-B, No. 2, FEBRUARY 2014 181

182 D. H. OWEN, N. C. RUSSELL, P. N. SMITH, W. L. WALTER

Table I. Studies included in the analysis of squeaking ceramic-on-ceramic (CoC) total hip replacement (THR)

Revision for
Author Year Total THR CoC THR followed up Mean follow-up (months) Method Squeaking (%) squeak (%)
Restrepo22 2008 1056 1056 22.8 Self-reported 2.8 0.6
Baek34 2008 100 71 85.2 Questioned 1.4 0
Capello35 2008 380 380 99.6 Questioned 0.8 0
Ecker60 2008 2414 2414 - Self-reported 1.2 0
Garcia-Cimbrelo11 2008 319 314 56.4 Questioned 0 0
Keurentjes30 2008 43 43 47.3 Questioned 20.9 4.7
Chang72 2009 42 42 64.8 Self-reported 0 0
Greene73 2009 103 102 50.4 Self-reported 4.9 0
Jarrett38 2009 159 149 22 Questioned 10.7 0
Kim53 2009 105 100 67.2 Questioned 0 0
Mai40 2009 336 320 46.8 Questioned 10.00 0
Kim74 2010 102 93 133.2 Self-reported 1.08 0
Boyer50 2010 83 76 120 Questioned 1.3 0
Choi37 2010 192 173 87.6 Questioned 4.6 0
Hamilton6 2010 177 157 31.2 Self-reported 0 0
Lee52 2010 100 88 131 Questioned 1.1 0
Lewis49 2010 30 27 96 Self-reported 0 0
Lombardi13 2010 65 63 73 Self-reported 0 0
Park51 2010 112 102 115 Questioned 0 0
Petsatodis75 2010 109 85 249.6 Self-reported 0 0
Restrepo21 2010 1486 1486 66 Questioned 6.4 0.7
Restrepo57 2010 304 304 60 Questioned 10.5 2.0
Swanson39 2010 306 270 59.1 Questioned 8.9 0
Amanatullah47 2011 196 125 60 Self-reported 0 0
Cogan26 2011 284 265 42 Questioned 2.6 0
Hwang46 2011 115 78 60 (Minimum Follow-up) Self-reported 1.3 0
Ki58 2011 61 61 69.5 Questioned 23.0 0
Parvizi71 2011 1756 1756 50.4 Questioned 5.6 0.6
Schroder23 2011 436 375 42 Questioned 2.4 0
Sexton24 2011 2406 2406 127.2 Questioned 3.1 0
Solarino45 2011 35 33 80 Self-reported 3.0 0
Stafford44 2011 272 250 59 Questioned 0 0
Szymanski48 2011 144 132 74 Questioned 8.3 0
Byun76 2012 56 55 86.4 Questioned 1.8 0
Chevillotte36 2012 100 89 120.5 Questioned 5.6 0
Finkbone77 2012 24 22 53 Self-reported 0 0
Haq25 2012 1002 1002 29 Self-reported 1.5 0
Kim42 2012 137 127 175.2 Self-reported 0 0
Nikolaou54 2012 34 34 60 Self-reported 8.8 -
Owen31 2012 70 69 85.2 Questioned 24.6 0
Porat78 2012 1757 1697 60 Self-reported - 0.2
Sugano43 2012 100 93 148.8 Questioned 0 0
Yeung41 2012 301 244 130.8 Questioned 0.4 0
Total 17 409 16 828
*Not recorded; HHS, Harris hip score; UCLA, University of California, Los Angeles; BMI, Body Mass Index; SF-36, Short Form 36.

eligible for analysis if either or both the incidence of squeaking
and the incidence of revision for squeaking could be deter-
mined. Studies were excluded if both of these numbers were
missing or could not be calculated. Where there were multiple
publications using the same dataset, only the most recent pub-
lication was considered.
In all, 43 studies met the inclusion criteria with a total of
17 409 THRs of which 16 828 were CoC (Table I). These
studies were then assessed to identify the incidence of
squeaking and of revision for squeaking and any patient
awaiting revision, which was taken to represent the upper
incidence of revision for squeaking. The incidence of
squeaking and noise as defined by each study at the most
recent follow-up left a total of 16 828 CoC hips. Squeaking
was not reported by Porat et al,79 thus this study was
excluded from the calculation estimating the incidence of
squeak; similarly revision for squeak was not reported by
Nikolaou et al,54 thus this study was excluded in the revi-
sion for squeak calculation. Whether the squeak was self-
reported or identified following specific questioning was
also recorded. The AOANJRR was consulted with regard
to the incidence of revision surgery for squeaking.
Statistical analysis. Incidence rates were modelled using a
-binomial distribution to account for an over-dispersed
binomial distribution. These estimates were calculated
with R statistical analysis software version 3.0.0 (The

THE BONE & JOINT JOURNAL

 AN ESTIMATION OF THE INCIDENCE OF SQUEAKING AND REVISION SURGERY FOR SQUEAKING IN CoC THR
30
Specifically
questioned
25
Incidence of squeak (%)
Self reported
20
15
10
5
0 0
0 500 1000 1500 2000 2500 3000
Number of hips
Fig. 1
Funnel plot showing the incidence of squeaking and number of hips.
The incidence of squeaking is higher in studies that specifically ques-
tion patients about it than in studies where squeaking is self-reported.
R Foundation for Statistical Computing, Vienna, Austria)
and its Vector Generalised Linear and Additive Models
(VGAM) package. Microsoft Excel (Microsoft, Redmond,
Oregon) was used to construct charts, and a paired Stu-
dent’s t-test was used to test differences between study
groups. A p-value 0.05 was considered significant.
Results
Reported incidence of THR squeaking. Of the 15 131 CoC
hips included in studies that reported squeak, 545
squeaked, giving an incidence of 4.2% (95% confidence
interval (CI) 2.7 to 6.4). A funnel plot of the incidence of
squeaking in THR against the number of hips studied is
shown in Figure 1. This demonstrates a significantly lower
incidence of squeaking of 1.2% (95% CI 0.6 to 2.6) in self-
reported studies, compared with studies that used specific
questioning (4.5%) (95% CI 3.5 to 5.8) (p = 0.002). No
difference in incidence of squeaking in THR was found
between large series ( 500 hips) (3.4%) (95% CI 2.4 to
4.8) and smaller series (3.9%) (95% CI 2.5 to 6.2)
(p = 0.59). There is a lower incidence of THR squeaking
in studies with a follow-up of > 100 months (2.4%)
(95% CI 1.3 to 4.6) than in studies with < 100 months’ fol-
low-up, with an incidence of 4.6% (95% CI 3.5 to 61), but
this difference was not statistically significant (p = 0.82).
Figure 2 demonstrates the relationship between squeak and
duration of follow-up in self-reported studies and in
patients questioned about THR squeaking.
We found a significantly higher incidence of squeaking of
8.3% in CoC THRs with the non-cemented Stryker Acco-
lade femoral (Stryker Orthopaedics, Mahwah, New Jersey)
component (95% CI 5.9 to 11.5, n = 242/2924) than with
other femoral components (cemented and non-cemented)
(1.9%) (95% CI 1.3 to 2.8, n = 193/9973) (p < 0.001).
These numbers were derived from studies or groups of hips
VOL. 96-B, No. 2, FEBRUARY 2014
183
30
Specifically
Incidence of squeak (%)
25 questioned
Self reported
20
15
10
5
0 50 100 150 200 250 300
Follow-up (months)
Fig. 2
Funnel plot showing the incidence of squeaking, with mean follow-up
with trend line; there is no change in the incidence of squeak with fol-
low-up.
within the included studies, where the incidence of squeak
could be calculated. The incidence of squeak for other
designs of femoral component is not given due to the small
amount of available data.
The presence of other noises, not defined as squeak
(which included pops, clicks, grating and grinding), was
reported in 25 studies.6,11,23,26,31,34-53 The incidence of these
noises was 7.5% (95% 4.4 to 12.4, n = 309/4073).
Reported incidence of revision THR for squeaking. The inci-
dence of revision for THR squeaking has been reported to
range between 0% and 4.7%.30 Using the data obtained
from the studies included in our analysis that reported on
revision surgery for squeak (Nikolaou et al54 excluded), we
estimated the incidence of revision for squeak to be 0.2%
(95% CI 0.08 to 0.57, n = 41/16 794). The AOANJRR
reports a revision rate for squeaking of 0.03% for all CoC
THRs (n = 55 417).
The AOANJRR includes 2955 CoC THR with the Acco-
lade stem of which five were revised for squeaking (0.17%).
The overall rate of revision for this stem is equivalent to that
for other types of non-cemented CoC THR. To be recorded
as revision for squeak, squeak must be specifically recorded
in the ‘other diagnosis’ section of the revision hip reporting
form.1 According to our analysis the revision rate for the
Accolade stem is 1.3% (95% CI 0.6 to 2.6 n = 7/556), which
was significantly higher (p < 0.001) than other femoral com-
ponents (0.02%) (95% CI 0.0050 to 0.079, n = 2/9939).
Although revision THR for squeaking is a rare occurrence,
a number of studies report patients with a high-grade frequent
squeak considering or waiting for revision. If this is taken as
an upper boundary of revision for squeaking, the incidence
becomes 0.30% (95% CI 0.16 to 0.72, n = 47/12 530).
Discussion
Definition and assessment of squeaking. Squeaking in THR is
defined as an audible sound that emanates from the hip with
184 D. H. OWEN, N. C. RUSSELL, P. N. SMITH, W. L. WALTER
Fig. 3
Diagram showing proposed mechanisms and associations of squeak-
ing in ceramic-on-ceramic total hip replacements.
movement.39 It has been further defined by some authors to
include grinding, clicking or grating that is reproducible,30 or
which can be heard by other people.31,39 In a study recording
noise from a number of different THR bearing types, a vari-
ety of sounds including pops, snaps and thuds, knocking,
crunching, grating, cracking and squeaking were reported,
with the notable distinction that the CoC bearing couples
produced sound throughout the gait cycle.55
Some authors have attempted to grade the squeak based
on loudness, perceptibility to others and frequency of occur-
rence.35,39,56 Others have classified squeaking as ‘problem-
atic’ or ‘concerning’ in terms of social impairment, and
investigated when patients would want revision surgery for
squeaking.31 Unfortunately, there is no universally accepted
classification system. Similarly, there is no validated assess-
ment standard by which to determine the presence of
squeaking in THR, which may have influenced the reported
incidence.1,38,57 It is possible to speculate that squeaking in
THR is under-reported in studies that rely on patients to vol-
unteer this information whereas it appears that a specific
enquiry results in higher incidences being reported.1
Reported incidence of squeak. This study estimates an inci-
dence of CoC THR squeaking of 4.2%, which is higher
than the 2.4% reported in a recent meta-analysis.56 The
recent meta-analysis by Stanat and Capozzi56 used
12 studies, including two series that were re-reported in
later publications.18,57 The incidence of squeaking in CoC
THR has been variably reported, ranging from 0% to
37.5% in a subset of Korean patients,58 and as high as
35.6% in patients receiving Accolade femoral compo-
nents.39 Squeaking in THR has been observed to be varia-
ble, with a small proportion of patients in some studies
describing a change in frequency and even cessation of the
squeak over time.24,31 Others, however, have not reported
any change,36 and some have reported an increase in
squeaking with extended follow-up.31 Squeaking is recog-
nised to take some time to manifest itself, with no reports of
squeaking immediately post-operatively and some reports
demonstrating late-onset squeaking.39,59
Incidence of revision for squeaking. Our estimate of revi-
sion for CoC THR squeak is 0.2%. Although few studies
report revision surgery for squeaking, a high rate of revi-
sion of 4.65% was reported in a series of 43 hips.30 Else-
where, six squeaking THRs in a series of 304 were revised
(1.97%).57 Based on studies reporting on patients contem-
plating or waiting for revision surgery,18,25,38,39,58 a worst
case revision rate for squeak is recalculated as 0.3%.
Mechanism of squeaking. There are essentially two mecha-
nisms described. The first involves sound that is generated by
extra-articular impingement of the femoral neck on the ace-
tabular component.59,60 A second process is said to be
dependent on increased friction of the bearing couple, caus-
ing resonance and the production of audible noise61 (Fig. 3).
Factors linked to squeaking in a CoC THR are shown in
Table II. Squeaking was first linked to rim impingement in
a case report in 2003,59 and has been proposed again more
recently.18 Rim impingement is noted to be common in con-
ventional THR62 and is associated with short neck
length.30,59 It is also associated with elevated metal rims of
acetabular components.39,60,63
A number of studies have considered acetabular orienta-
tion and its role in the production of squeaking.18,21,24,25,39
In addition to an increased probability of neck–rim
impingement, the proposed mechanism is edge loading.
This leads to localised stress and wear on the head, termed
stripe wear.39 Using finite element analysis, eccentric load-
ing of the femoral head has been modelled and investigated
in the laboratory, with high inclination and anteversion
shown to increase edge loading, wear and squeaking.63,64 In
contrast to these findings, some retrieval studies have
reported evidence of rim impingement with normal acetab-
ular orientation,22 and some have shown no relationship
between squeaking and acetabular orientation.30,37-39
The ‘increased friction hypothesis’ contends that squeak
is a result of reduced lubrication. This was proposed by
Reiker et al65 in metal-on-metal articulations, where it was
postulated that a slip-and-stick mechanism leads to noise
by generating vibration. This is easily reproduced in the
laboratory with a dry joint.20 Alteration of the bearing
surface65 by roughening or by metal deposition can also
produce squeaking.29,66 Disruption of fluid film lubrication
THE BONE & JOINT JOURNAL
 AN ESTIMATION OF THE INCIDENCE OF SQUEAKING AND REVISION SURGERY FOR SQUEAKING IN CoC THR
Table II. Studies demonstrating factors associated with CoC THR squeak.
Study Significant associations
Walter18 High anteversion variance, high inclination variance,
taller, heavier and younger patients
Ecker60 Stryker Accolade stem and Stryker Trident acetabular
component combination
Restrepo22
Keurentjes30 Short femoral neck length
Jarrett38 Negative quality of life
Mai40 Height, smaller neck geometry, neck-cup combination
with combinations other than C-taper/ABC, V40 neck
Choi37 Male gender, larger head size
Restrepo21
Restrepo57 Accolade stem
Swanson39 Accolade stem/Trident acetabular component, RA,
short femoral neck
Cogan26 Association between noise and dissatisfaction
Schroder23
Sexton24 Age, height, weight, adduction, external rotation,
internal rotation, activity subgroup of HHS
Parvizi71 Trident cup
Ki58
Chevillotte36 Gender, weight, acetabular component size, femoral
component size, UCLA score
Haq25 BMI inclination, limb length shortening of >5mm
Owen31
BMI, body mass index; HHS, Harris hip score; UCLA, University of California, Los Angeles; SF-36, Short Form 36; RA, rheumatoid arthritis; TMZF®,
titanium, molybdenum, zirconium and iron alloy (Ti-12Mo-6Zr-2Fe); C-taper/ABC, neck and cup combination (arc-deposited hydroxyapatite-coated
cup), Stryker, Mahwah, New Jersey; Trident Cup (Stryker, Mahwah, New Jersey.)
has been related to edge loading and stripe wear.18,67,68 In
contrast to these observations, stripe wear has been observed
on a large number of femoral heads that do not squeak.68
Micro-separation, which describes micro-subluxation of
the femoral head,69 occurs during the gait cycle, where the
femoral head is eccentrically loaded causing localised stress
and stripe wear. Experiments incorporating micro-separa-
tion produce wear stripe patterns similar to that seen in
retrieval analysis.68 Squeaking has been linked to a patient’s
predisposition to micro-separation, including those with
ligamentous laxity and leg-length shortening.38,69
Femoral stem design has been linked to squeak produc-
tion by laboratory, clinical studies and meta-analysis.
Stanat and Capozzi56 showed a significant association with
the implantation of the Accolade stem. Walter et al70 noted
that the acetabular component construct resonates above
the audible range of human hearing. Hothan et al28 con-
ducted laboratory experiments examining the natural fre-
quency of THR components and concluded that the design
of the femoral, and not the acetabular component, was
responsible for generating audible sound. Of the designs
examined, the Accolade stem was shown to be particularly
prone to this phenomenon.
There is controversy over which patient factors are
associated with squeaking in CoC THR. In a recent meta-
analysis Stanat and Capozzi56 found that elevated body
VOL. 96-B, No. 2, FEBRUARY 2014
185
No association
Pain scores, HHS, inclination, anteversion
Inclination, anteversion, age, gender, BMI, indication, complications, cup
size, head size, stem size
No statistical difference between inclination, anteversion, leg length, head
size distribution
Age, gender, weight, BMI, side, unilateral/bilateral, indication, head size,
acetabular component
Age, height, weight, BMI, abduction angle, cup size, neck length
Gender, age, height, weight, BMI, follow-up, acetabular components, femo-
ral component, head size, SF-36, anteversion, inclination
Gender, height, BMI
Age, gender, height, weight, BMI, side, UCLA score, head size, femoral off-
set, inclination, anteversion
Inclination
BMI, hip flexion, abduction, HHS, patient satisfaction, head size
TMZF® stem, operating surgeon
Inclination, anteversion
Age, BMI, HHS, Postel-Merle score, surgical approach, neck length
Age, acetabular anteversion, HHS
Height, weight, BMI, age, indication
mass index alone was linked to squeaking. Sexton et al24
found squeaking to be associated with heavier, taller,
younger people. Other series have found a relationship with
male gender and higher activity scores.
In conclusion, the incidences of squeaking in CoC THR
and of revision for squeaking are estimated to be 4.2% and
0.2%, respectively, but these estimates are considerably
higher when the Accolade femoral component is used.
The exact mechanism of squeaking in THR remains a
matter of conjecture and is probably multifactorial. This
review demonstrates that squeaking in CoC THR, although
rare, is not insignificant. Although there is not yet any defin-
itive evidence to suggest that regular squeaking reduces the
survival of the THR, there are a number of studies that have
related squeaking to increased wear and suboptimal posi-
tioning, which may suggest at future problems.
It is important to acknowledge that the vast majority of
CoC THRs perform as expected, providing patients with
significant relief from pain and return to function.
Although some patients are troubled by the squeak, many
remain unconcerned and very few seek revision surgery.
The authors wish to thank Dr Terry Neeman for her help and advice with the sta-
tistical analysis.
No benefits in any form have been received or will be received from a com-
mercial party related directly or indirectly to the subject of this article.
This article was primary edited by G. Scott and first-proof edited by D. Rowley.
186 D. H. OWEN, N. C. RUSSELL, P. N. SMITH, W. L. WALTER
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