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Influence of Prosthetic Design on Squeaking after
Ceramic-on-Ceramic Total Hip Arthroplasty
Todd V. Swanson, MD • Raghavendran Seethala, MS • David J.
Peterson, PharmD, DO • Ryan Bliss, BBA • Calvin Spellmon, BS • Las
Vegas, Nevada
DISCLOSURE: No author has received anything of value or owns
stock in any company or institution related directly or indirectly
to the subject of this study.
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Squeaking ceramic-on-ceramic total hip articulations are a cause
for concern. Although used in Europe for almost 40 years, ceramic-on-ceramic hips did not exhibit a significant problem
with squeaking until FDA approval of two ceramic hips in 2003. Since then, many studies have attempted to elucidate the
etiology of squeaking. Proposed causes include component malposition causing impingement or “edge
loading,”ligamentous laxity leading to microseparation and “stripe wear,” inadequate lubrication, particulate metal debris, and
component design. The primary author began implanting ceramic-on-ceramic total hips in
1999. Over the course of 10 years, four distinct implant brands were utilized. However, an unusually high incidence
of intense, audible squeaking became apparent shortly after implanting a cohort of Stryker Trident acetabular
components and Accolade femoral stems. This study was undertaken to determine if squeaking is related to this particular
implant combination and to elucidate any other factors which might be related to squeaking.
From November 1999 through February 2007, the primary author
implanted 306 ceramic-on-ceramic total hip arthroplasties in 267 patients. Four acetabular component designs were used: 1)
*Plus Orthopedics MPF, 2) Stryker Trident PSL, 3) Wright Medical Lineage, and 4) Encore Keramos. Femoral components
used were the Plus Orthopedics SL-Plus, Stryker Accolade, and Wright Medical Profemur-Z. In this study, 233 patients with 270 total hips were contacted
telephonically to complete a survey regarding squeaking of their hip prostheses. Only patients with a minimum 24 months
follow-up were included in this study. Demographic and operative data were collected by questionnaire and review of the
patients’ medical records. Additionally, all patients who reported squeaking were matched with
controls based on nine matching criteria. Acetabular abduction and anteversion angles were measured from plain
radiographs and compared using Student’s t test. Frequency and severity of squeaking were graded as shown in Table 1.
“PROBLEM SQUEAKING”was defined as squeaking which was always perceptible to others (Severity Grades 3-4) and
occurred at least once per week (Frequency Grades 2-4). Twelve independent variables (Table 2) were analyzed using a
logistic regression analysis with additional Chi-square analysis where appropriate to determine variables associated with
squeaking...
...Based on the findings of this study, the authors recommend
against the use of the Stryker Trident cup with the Accolade stem and the use of short necks in ceramic-on-ceramic total hip
arthroplasty. Ceramic-on-ceramic articulations should be used with caution in rheumatoids. Further research will likely
elucidate the mechanisms causing problem squeaking in these subgroups of patients.
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