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Natural history of noise and squeaking in cementless ceramic-on-ceramic total hip arthroplasty
, Sumihisa Oritac, Seiji Ohtorib
∗Corresponding author: Kenta Inagaki. sp.i.md1988@gmail.com
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Ceramic-on-ceramic (COC) total hip arthroplasty (THA) was developed to reduce wear debris, and consequently the occurrence of osteolysis and aseptic loosening. The purpose of the present study was to determine the incidence and natural history of noise including squeaking after COC THA, and to clarify whether clinical outcomes and any demographic and implant-related factors are associated with noise from these ceramic bearings.
This was a retrospective observational study of 137 primary COC THAs between 2004 and 2009 at our institute. The Mean follow-up was for 10.5 years. All patients were followed up with an office visit to obtain information regarding noise, pain, and function. The correlations between the noise, and patient demographic, radiographic, and implant-related factors were evaluated.
Noise developed in 30 hips (21.9%), specifically squeaking in 2 (1.5%) of the 137 hips during the follow-up period. Noise including squeaking was not associated with pain or functional outcomes. There was significant correlation between noise and cup anteversion, in that cup anteversion of patients with noise was smaller than that in those without noise. No significant correlation was found between noise and any other patient demographic including age, sex, height, body weight, or body mass index. Kaplan–Meier survivorship analysis with revision for any reason and an aseptic loosening of either component as the end point, revealed a cumulative survival rate at 10 years of 98.4% and 99.1% respectively.
The long-term clinical and radiographic outcome of cementless COC THA is excellent, but we should be vigilant for noise from COC bearings.
Keywords
Ceramic-on-ceramic
Total hip arthroplasty
Cementless
Noise
Squeaking
Clinical outcome
Radiographic outcome
1 Introduction
Ceramic-on-ceramic (COC) bearings for total hip arthroplasty (THA) have had a long and successful history, but several specific complications are noted including component loosening, ceramic fracture, and noise including squeaking.1–12 Noise has been a disadvantage of COC THA, and a variety of noises including “grinding,” “clicking,” and “squeaking” have been noted. The incidence of noise has been reported to range from <4.5% to 32.8% and squeaking has been reported from 1.1% to 10.7%.1–13 The etiologies of noise generation have been reported to implicate patient factors, implant factors such as malposition and various design combinations, and factors specific to the bearing surface itself, such as lubrication disruption, metal transfer, microseparation, and third-body mechanics. A few articles have reported the natural course of noise generation and association between noise and clinical outcomes, such as pain and function.
The present article reports the long-term clinical outcome of cementless THA with COC bearings, and we compared the frequency of noise including squeaking at 1st screening with that at 2nd screening and the correlation between noise and clinical outcomes.
2 Methods
2.1 Study design and population
The research protocol of this study was approved by the institutional review board of Matsudo City General Hospital in compliance with the principles of the Helsinki Declaration and its contemporary amendments. From May 2004 through February 2009, cementless THA with third-generation COC bearings was performed in 149 hips of 126 patients. The indication for a COC cementless THA during the study period was an active adult patient with good femoral bone-quality (femoral cortical index of more than 50%). Except for 12 hips (2 hips lost because of death, 10 hips lost to follow-up), 120 patients and 137 hips were reviewed clinically and radiographically. The average duration of follow-up was 10.5 years (range 5.2–13.5 years) with a minimum 5-year follow-up. The average age, height, body weight, body mass index (BMI), and sex were illustrated in Table 1. The patients had undergone 59 hip replacements on the left side and 77 hip replacements on the right side. Osteoarthritis was present in 134 hips, osteonecrosis in 2 hips, and rheumatoid arthritis in 1 hip.
| Variable | Total number of hips (n) | ||
| with noise including squeaking | without noise including squeaking | p value | |
| Age (years)a | 59.9 (41–74) | 59.9 (41–74) | 0.367 |
| Female/male | 30/0 | 100/7 | 0.824 |
| Height (cm)a | 152.2 (138.8–168.3) | 152.2 (138.8–168.3) | 0.962 |
| Body weight (kg)a | 57.3 (44.3–87.1) | 57.3 (44.3–87.1) | 0.137 |
| BMI (kg/m2)a | 23.8 (18.2–34.2) | 25.1 (17.7–37.7) | 0.161 |
All of the liners and femoral heads were made of Biolox Forte ceramic (CeramTec, Plochingen, Germany), and the acetabular components were hemispherical titanium cups (Plasmacup; Aesculap, Germany) with an outer coating of plasma-sprayed pure titanium (Plasmapore; Aesculap, Germany). The cementless femoral components were slightly tapered, rectangular, collarless titanium-alloy implants (BiContact; Aesculap, Germany). The proximal one-third of the stems was coated with Plasmapore. The modular ceramic femoral heads were secured with a Morse taper, and the alumina acetabular inserts were secured using a self-securing conical fit. A THA through a lateral approach with the patient in a lateral position was used for 31 hips, and a direct anterior approach with the patient supine was used for 106 hips.
2.2 Clinical assessment
The patients were evaluated prospectively, and data were reviewed retrospectively by several senior orthopedic surgeons. Clinical outcome was assessed in all patients using the Japanese Orthopedic Association (JOA) score (total 100 points) based on pain (40 points), range of motion (ROM) (20 points), walking ability (20 points), and activities of daily living (20 points).14 We screen and asked the patients about occurrence of any noise in the affected hip and pain associated with noise twice postoperatively and classified the frequency and the severity of any noise (Table 2). The mean follow-up at 1st and 2nd screening was 3.8 years (range, 3–5 years) and 10.5 years (range, 5–13 years), respectively. Furthermore, the patients with the noise were asked about audibility of the noise to others nearby, whether the noise could be reproduced in the outpatient clinic, and activities or postures relating to the noise. In this study, we classified noise severity type 3 as describing “creak or squeak” audible to others nearby.
| Grade | Frequency | Type | Severity |
| 0 | Nothing | 0 | Nothing |
| 1 | Not now, but appeared in the past | 1 | Clicking without audible sound |
| 2 | Sometimes appears (a few times in a week) | 2 | Clicking and sound audible to self; however, inaudible to others nearby |
| 3 | Appears almost every day | 3 | Sound audible to others nearby and some limitations of ADL |
2.3 Radiological analysis
Radiographs were evaluated for radiolucent lines, osteolysis, femoral neck fretting,15 and loosening. The locations of radiolucent lines and osteolysis were assessed with the zone in the femoral component described by Gruen et al.15 and with the zone in the acetabular component described by Delee and Charnley et al.16 Fretting of the neck in the femoral component was assessed with AP and frog lateral pelvic radiographs. Cup alignment (anatomical abduction angle and anatomical anteversion angle), stem anteversion angle, and total anteversion of Widmer17 were measured. The inclination angle was assessed from anteroposterior (AP) pelvic radiographs taken 3 months postoperatively. The radiographic anteversion was converted from anatomical anteversion, which was assessed with computed tomography (CT) using the formula of Murray et al.18 Stem anteversion was measured using the angle of the neck axis and the posterior condylar line of the knee with CT.
2.4 Statistical analysis
An independent-samples Student t-test was used to compare groups in terms of cup abduction angle, cup anteversion angle, stem anteversion angle, and total anteversion. We evaluated differences between the frequency and severity of any noise at the 1st screening after operation, and those at the 2nd screening. Kaplan–Meier survival analysis was conducted using 2 end points: revision for any reason, and aseptic loosening of either component. We considered p < 0.05 significant in tests of statistical inference. All statistical analyses were performed using EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan), which is a graphical user interface for R (The R Foundation for Statistical Computing, Vienna, Austria).
3 Results
Noise developed in 30 (21.9%) of 137 hips during the follow-up period, and of these squeaking in 2 (1.5%). At the 1st screening noise developed in 10 hips (7.3%), and at the 2nd screening noise developed in 26 hips (19.0%). There was significant difference in noise development between the 1st screening and the 2nd screening (p < 0.001). Six of 10 hips that produced noise at the 1st screening also had noise at the 2nd screening, but 4 of 10 hips did not produce any perceivable noise. By contrast, 20 of 127 hips (15.7%) that did not produce any noise at the 1st screening newly produced noise at the 2nd screening. The alterations of noise between the 1st screening and the 2nd screening are illustrated in Fig. 1.
The activity that was most commonly reported to elicit noise was forward bending in 8 patients. The remaining activities were sitting in 3 patients, standing in 2, high reaching by extension and external rotation of the hip in 1, and unknown in 17. In one hip noise (squeaking) was reproduced in a follow-up visit; however, no noise could be reproduced by others. No patient perceiving any noise complained of pain associated with the noise, including squeaking. The mean JOA score improved from 42.1 points (range, 12 to 71 points) preoperatively to 91.4 points (range, 76 to 98 points) at the latest follow-up (p < 0.001). There were no significant differences in JOA total score, pain score, and ROM score between the patients with the noise and those without.
The noise frequency and severity at the 1st screening and 2nd screening was illustrated in Table 3. Between 1st screening and 2nd screening, 20 hips (15.7%: 95% confidence interval, 9.3%–22.1%) without noise changed to be in grade 2 or 3, and 107 (84.3%: 77.9%–90.7%) without noise continued to be without noise. There were alterations of the noise severity between 1st screening and 2nd screening. Furthermore, one hip in type 3 (squeaking) at 1st screening that remained in type 3, subsequently underwent an anterior dislocation and had a fracture of the ceramic liner.
| 1st screeningNumber of hips, n (%) | 2nd screeningNumber of hips, n (%) | ||||
| Grade 0 (n = 107) | Grade 1 (n = 4) | Grade 2 (n = 23) | Grade 3 (n = 3) | ||
| Noise frequency | Grade 0 (n = 127) | 107 (84.3%) | – | 19 (15%) | 1 (0.7%) |
| Grade 1 (n = 0) | – | – | – | – | |
| Grade 2 (n = 10) | – | 4 (40%) | 4 (40%) | 2 (20%) | |
| Grade 3 (n = 0) | – | – | – | – | |
| Type 0 (n = 111) | Type1 (n = 21) | Type2 (n = 3) | Type3 (n = 2) | ||
| Noise severity | Type 0 (n = 127) | 107 (84.3%) | 18 (14.2%) | 2 (1.6%) | – |
| Type1 (n = 3) | 1 (33.3%) | 2 (66.7%) | – | – | |
| Type2 (n = 6) | 3 (50%) | 1 (16.7%) | 1 (16.7%) | 1 (16.7%) | |
| Type3 (n = 1) | – | – | – | 1 (100%) | |
Comparisons of the implant position radiographically between hips with noise and those without are shown in Table 4. There was a significant correlation between noise development and cup anteversion, in that cup anteversion in patients with noise was significantly smaller than that in those without.
| Implant | ||||||||
| Position (degree)a | Factors, Number of hips, n (%) | |||||||
| Cup | Stem | Total | Neck | Head diameter (mm) | ||||
| Taper design | length | |||||||
| Abduction | Anteversion | Anteversion | Anteversion | 8/1012/14 | SmallMediumLong | 2832 | ||
| Noise including squeakingNumber of hips, (n) | Positive (n = 30) | 40.8 (±5.4) | 18.5 (±8.5) | 24.3 (±11.1) | 41.4 (±17.7) | 24 (80)6 (20) | 4 (13.3)16 (53.3)10 (33.3) | 29 (96.7)1 (3.3) |
| Negative (n = 107) | 40.4 (±5.1) | 22.3 (±9.0) | 20.9 (±11.5) | 40.4 (±18.2) | 83 (77.6)24 (22.4) | 13 (12.1)52 (48.6)42 (39.3) | 104 (97.2)3 (2.8) | |
| p value | 0.697 | 0.044 | 0.156 | 0.79 | 1.0 | 0.84 | 0.62 | |
No significant correlations were found between the noise development and any demographic factors including age, sex, BMI, height, or weight. There was no significant correlation between the noise development and implant factors of including neck taper design of the stem, neck lengths, or head diameters (Table 4). Four (2.9%) of 137 hips had a radiolucent line around the acetabular component; 1 hip in Delee and Charnley Zone 1, and 4 hips in Zone 2. There were 17 (12.4%) of 137 hips with a radiolucent line around the femoral component, 1 hip in Gruen Zone 1, 1 in Zone 2, 7 in Zone 3, 3 in Zone 4, 10 in Zone 5, 9 in Zone 6, and 1 in Zone 7. There was no osteolysis; however, fretting of the neck of the femoral component was observed in 1 hip. The patient with the neck fretting perceived noise without squeaking at 5 years after their operation; thereafter, the noise had disappeared at 10 years. The design of the neck taper in this patient was 12/14 mm. The patient was asymptomatic, and at 12 years postoperatively no osteolysis or radiolucent line was observed radiographically. Aseptic loosening of the cup developed in 1 hip at 10 years after THA; thereafter, a solitary cup revision was performed with a cemented all-polyethylene component. The patient has not perceived any noise during follow-up.
Postoperative dislocations occurred in 3 hips. The dislocations were all directed anteriorly. Two hips that had undergone a direct anterior approach demonstrated anterior dislocation within 1 week postoperatively; thereafter, both affected hips have been stable after closed reduction. The other hip had undergone a lateral approach and had been silent postoperatively; it thereafter demonstrated an acute audible noise at standing 6 years after the operation and showed anterior eccentric displacement of the femoral head radiographically. In this case, the affected hip joint was extremely unstable after closed reduction, and consequently open reduction surgery was performed. During the surgery, a fracture of the ceramic liner and metal coloring of the femoral ceramic head was recognized, and the radiographs of the hip before and after reoperation are shown in Fig. 2. Solitary cup revision was performed with exchange of the fractured ceramic liner to a polyethylene liner retaining the metal-backed acetabular component. This patient had a severe kyphosis of the lumbar spine and a severe retroversion of the pelvis. One month after the revision surgery, anterior dislocation developed and anterior instability continued after closed reduction. Re-revision was performed with a cemented polyethylene cup augmented by an acetabular plate following removal of the stable metal-backed acetabular component. By contrast, there was no fracture of the ceramic femoral head in any patient. Fourteen (9.7%) undisplaced fractures of the proximal femur occurred intraoperatively, and 3 hips (2.1%) required prophylactic circular wiring.
Kaplan–Meier survivorship analysis based on 137 hips at risk, with revision for any reason (Fig. 3A) and an aseptic loosening of either component (Fig. 4) as the end points, revealed a cumulative survival rate at 10 years of 98.4% (95% confidence interval, 96.2%–100%) and 99.1% (97.4%–100%) respectively.
4 Discussion
The incidence of noise associated with COC bearings has been variably reported, and we suspect that the cause of this wide variation in noise incidence would come from ambiguous definitions of noise and squeaking. Choi et al.1 reported a low rate of squeaking (5%) using open-ended questions, and all patients who could reproduce a sound similar to squeaking were included in the squeaking group. Differences between questionnaires, methods and definitions of squeaking might produce widely different results for the incidence of noise and squeaking.
Claus et al.2 reported a high proportion (27%) of noisy hips from COC THAs. They used a questionnaire for the patients at follow-up visits and interviewed the patients by telephone when they were unable to visit. We asked patients directly at the follow-up visit whether they could perceive any noise including squeaking at present or in the past; hence, the incidence of noise in this study (21.9%) was relatively high compared with other studies.3–5 Many patients with noisy hips were often asymptomatic and could not reproduce the noise at the outpatient clinic in the present study. Therefore, these asymptomatic conditions associated with noise might underestimate the incidence of noise in COC bearing THA.
In the present study, there was a significant increase in the incidence of noise between 1st screening and 2nd screening (7.3% and 19.0% respectively), and several patients demonstrated some alterations of frequency and severity of noise during follow-up (Figs. 3 and 4). If a patient did not have any noise at the 1st screening, there was an 84.3% probability of continuing to be silent without noise at the 2nd screening (mean 10.5 years), and that there was a 40.0% probability of noise disappearing during the further follow-up. Goldhofer et al.6 reported an increase of noise with COC bearing THA; 7.3% at 2 years after surgery, and 17.4% at 5 years. This finding might indicate an alteration of patients’ conditions, which are related to noise development, such as lubrication of the wear surface, tenderness of muscles around the hip, or a third body in the joint space, such as ceramic debris. In terms of patient demographic factors, several studies reported the noise occurred in patients who were taller, heavier, younger and male or female.1,3,6–8 Thus, there is little consensus about patient demographics related to noise development. In the present study, there was no significant correlation between noise and any patient demographic. Several studies have found the squeaking does not affect pain, patient quality of life or satisfaction.1,3,6,7,12 By contrast, Gillespie et al.9 reported that 42 patients (30%) with noise production had lower satisfaction, mean hip, and SF-12 scores than those with silent hips. In the present study, there were no significant differences of pain, range of motion, walking ability and daily activities between the patients with a noisy hip and those without. Various authors have reported there were no complications or revisions in the noise or squeaking groups.1,3,8,9,11,12 By contrast, Restrepso et al.10 demonstrated that 9 of 88 patients with squeaking hip underwent revision arthroplasty for squeaking, and reported that retrieved components did not show any fractures of the alumina ceramic bearings or any signs of impingement or stripe wear. In the present study, we did not experience any revision from noise or squeaking; however, further follow-up was necessary for noisy hips.
The reported etiologies of noise implicate patient factors, implant factors such as malposition and various design combinations, and factors inherent to the bearing surface itself such as microseparation, lubrication disruption, metal transfer, and third-body mechanisms.4,17,19–23 Restrepso et al.10 reported a clear relationship between the prevalence of squeaking and the type of femoral component implanted, namely that patients managed using an Accolade stem (Stryker Orthopaedics, Mahwah, New Jersey) were more likely to have a noise than those managed using an Ominifit stem (Stryker Orthopaedics). Goldhofer et al.6 reported that the squeaking rate for 36 mm head diameter was lower than that for 40 mm, 44 mm, and 48 mm head diameters. In the present study, the designs of femoral and acetabular implants were identical; moreover, there was no significant difference between noise and taper designs, neck length, or head diameters. Thus, given the wide range of proposed etiologies of noise, a multifactorial mechanism is suggested. In terms of the correlation between noise and implant position, Walter et al. reported that if the acetabular orientation is outside 15°–35° of anteversion and 35°–55° of abduction angle, the hip is 29 times more likely to develop noise.24 Lee et al. reported that only the cup abduction angle was a significant factor for the occurrence rate of squeaking, such as the occurrence rate tended to increase with increasing angle.25 Barrow et al.8 reported that patients with sounds were found to have less anteversion than those without. In the present study, we found cup anteversion in patients with a noisy hip was significantly smaller than that in those without noise; however, no significant correlation with cup abduction or total anteversion was found by Widmer's method. Because issues regarding noise are reported to be to multifactorial, a larger cohort and multivariate analysis are necessary to evaluate the correlation between noise development and implant position. We identified only one ceramic liner fracture in one female patient with severe kyphosis of the lumbar spine and pelvic retroversion. Edge loading following excessive cup anteversion might result in ceramic liner fracture. This patient perceived squeaking in the contralateral hip with a COC bearing. Pelvic retroversion should be considered an important risk factor for detrimental damage of the articular surface in COC bearings. At 10 years, 98.4% of the hips were not associated with any reoperation. This is an excellent implant survival result and comparable with another study.5 So, especially in terms of durability, COC bearings are a reasonable option for young and active patients.
The limitations of our study are as follows. First, we obtained data from a particular group of patients with good femur bone quality; therefore, the subjects in this study were not consecutive series. Second, we used a specific questionnaire for the patient directly at a follow-up visit to determine whether patients could perceive hip noise including squeaking. Some misinterpretation of hip noise by patients may have occurred, resulting in a higher reporting of noise. Third, we only investigated patients with COC bearings, and did not compare noise occurrence for COC bearings with the other type of bearings. Several investigators have reported higher rates of noise including squeaking for COC bearings compared with other bearings.4,6,12–15 Fourth, we did not obtain data for postoperative satisfaction or patient reported outcome. The development of noise can have a psychological impact on patients, sometimes leading to decreased satisfaction or quality of life.
In conclusion, the long-term clinical and radiographic outcomes were excellent; therefore, COC bearings are a reasonable option for young and active patients. Nevertheless, the possibility of noise including squeaking should be clearly demonstrated to patients who will undergo THA with a COC bearing. Further follow-up is necessary for patients with a noisy hip or risk factors for squeaking.
Funding
We did not receive any funding or financial support that may be perceived to have biased the study.
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