Squeaking in fourth-generation ceramic-on-ceramic total hip replacement and the relationship with prosthesis brands: meta-analysis and systematic review

Squeaking in fourth-generation ceramic-on-ceramic total hip replacement and the relationship with... Background: Postoperative squeaking in patients who applied the fourth-generation ceramic bearing in primary hip replacement has not been reported systematically; we aim to study the squeaking incidence in the fourth- generation ceramic bearing and related risk factors for squeaking, and we also attempt to explore the relationship between squeaking and prosthetic brands. Methods: The PubMed, Embase, and Cochrane library were searched, and 14 articles were finally included. Patients’ demographic data, surgical-related information, and prosthesis data were extracted. The occurrence rate of squeaking was calculated by meta-analysis, and subgroup analysis was performed based on prosthetic brands and follow-up time. Regression analysis was further applied to investigate the relationship between various risk factors and squeaking. Results: The squeaking incidence in patients with the fourth-generation ceramic bearing was 3%. Age, gender, body mass index, and abduction and anteversion angles of acetabular cup might have no influence on squeaking. The squeaking incidence was significantly high with the presence of Delta Motion cup (DePuy, Warsaw, Indiana) and Secure-Fit stem (Stryker, Kalamazoo, MI), and the overall incidence of DePuy femoral stem was relatively small except for the Summit femoral stem. And there was no significant difference of squeaking incidence between less than 5-year and more than or equal to 5-year follow-up subgroups. Conclusions: In our study, squeaking in the fourth-generation ceramic bearing occurred at a rate of 3%; occurrence rate was high when the Delta Motion cup was applied. We hope for more relevant researches to focus on this issue. Keywords: Squeaking, Fourth-generation ceramics, Total hip replacement, Prosthesis brands Background many years. Compared with the third generation, it Ceramic-on-ceramic bearing has been widely applied in added zirconia (18%), chromium oxide (< 1%), and total hip replacement for the biological inert, well wear- strontium oxide (< 1%) on the basis of alumina [3]. The ing capacity, and low inflammatory reaction caused by addition of these components reduced the risk for pros- wear particles [1, 2]. The fourth-generation ceramic thesis fracture [4], however, still could not get rid of bearing (BIOLOX Delta, CeramTec AG, Plochingen, squeaking [5]. Germany) has been used in total hip replacement for Squeaking was a high-pitched and audible sound, which was considered as a unique but unavoidable phenomenon in hard-on-hard bearing interface [6]. It * Correspondence: 2506053@zju.edu.cn; emilcai@163.com often appeared in painless or infrequent forms, but their Department of Orthopaedic Surgery, Second Affiliated Hospital of Zhejiang persistence might reduce patient satisfaction, or even University School of Medicine, Jiefang Road 88, Hangzhou 310009, China Orthopaedic Research Laboratory, Zhejiang University, Jiefang Road 88, cause revision surgery [7]. What is more, it also could be Hangzhou, China © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Zhao et al. Journal of Orthopaedic Surgery and Research (2018) 13:133 Page 2 of 9 an early sign of pressure peaks indicating incongruency Data extraction and a risk factor for component breakage [8]. Three authors (CCZ, GXQ, and XZC) retrieved the in- The mechanisms of squeaking were not yet fully cluded articles and extracted relevant data independently; understood; prosthesis factors have been regarded as an disagreements were resolved by discussion. Country of important contributor [6, 9]. There has been a study study, publication year, total number of patients, number comparing four kinds of femoral stems and a finding of patients with squeaking, and mean follow-up time were that the presence of Accolade femoral stem (Stryker, obtained. Moreover, patients’ demographic data (age and Mahwah, NJ) was significantly associated with hip gender) and body mass index (BMI) were collected, and in squeaking [10]. Indeed, different brands of prostheses some studies, BMI was indirectly calculated based on or different types of prosthesis with the same brand weight and height. Surgical information included the ab- had various designs and materials; we surmised that duction and anteversion angles of the acetabular cup squeaking incidence might be different when different which were identified by computerized tomography were types of prostheses were used. also abstracted. And above all, the brands of acetabular To our knowledge, there was no meta-analysis to cup and femoral stem were extracted. determine the occurrence rate of squeaking in the fourth generation of ceramic-on-ceramic total hip replacement. Quality assessment We aimed to explore the occurrence rate of squeaking The assessment of the methodological quality of each in the fourth generation of ceramic-on-ceramic total hip study was performed with the Consolidated Standards of replacement. The second purpose was to determine the Reporting Trials checklist [12]. Each study was scored risk factors for squeaking. Moreover, we also attempted by two of the authors (ZCC and QGX) based on the to observe the occurrence rate in different prosthetic scale, in which 22 questions were presented and the brands and find the possible relationship between squeak- score was 1 for “Yes” and 0 for “No or unclear.” The ing and prosthetic brands. disagreements were resolved by discussion. Methods Statistical analysis Search strategy We used the R software for statistical analysis. The results This meta-analysis was completed in accordance with were presented as weighted mean difference with 95% the reported guidelines [11]. The PubMed, Embase, and confidence interval or mean values. Incidence of squeak Cochrane library were searched before 22 January 2018 (p) was calculated by total hips (n) and the number of hips by using the following strategy: “hip and ceramic,”“hip with squeak (x)(if np > 5 and n (1 − p) > 5, then p = x/n, and squeak,”“hip and squeaking,”“hip and noise,”“hip SE (p)= √p (1 − p)/n;if np <5 or n (1 − p) < 5, then p =ln and sound,”“arthroplasty and squeak,”“arthroplasty and (x/(n − x)), SE(p)= √1/x +1/(n − x). Heterogeneity between squeaking,”“arthroplasty and noise,”“arthroplasty and the included studies was evaluated by the Q statistic, τ , sound,”“arthroplasty and ceramic,”“squeak and delta,” and I statistic [13], and the fixed effect model would be and “squeaking and delta.” The results were combined, applied if P > 0.1 and I < 50%; otherwise, the random and the repeated publications were excluded; only English effect model would be used (P < 0.1 and I > 50%). Sensi- language and human studies with full text available were tivity analysis was further conducted to assess the robust- included. When several publications from the same study ness and reliability of the pooled results. The publication population were found, the most recent or most detailed bias was evaluated by funnel plots. All results were pre- one was chosen in our analysis. sented in the form of forest plots, and P values less than 0.05 was considered statistically significant. Selection criteria The title and abstract of the literatures were reviewed by two of the authors (CCZ and GXQ). After a preliminary Results screening, we read the full text that possibly met the cri- Search results teria. Studies were included according to the following cri- We conducted the search based on the mentioned key- teria: (1) underwent primary total hip replacement, (2) words and initially identified 3516 relevant articles. After applied the fourth-generation ceramic bearing, (3) clearly reviewing the titles and abstracts, 114 articles were further reported the prosthetic brands, (4) reported squeak or evaluated for eligibility. Then, we found 17 articles might noise as an outcome or complication, and (5) randomized satisfy the inclusion criteria through full text reading, but controlled trials and cohort or cross-sectional studies. one did not explicitly report the patients’ number using Literatures which have not specifically point out whether the fourth-generation ceramics [14], and one got conclu- the third or fourth generation of ceramic bearing applied sions from the same population [15], and one was a case were excluded. report [5]. Finally, the remaining 14 articles were included Zhao et al. Journal of Orthopaedic Surgery and Research (2018) 13:133 Page 3 of 9 for meta-analyses [16–29]. The flowchart of literature se- group was as high as 13%, significantly higher than that lection was shown in Additional file 1: Figure S1. in the other three groups (P < 0.001). The squeaking incidence was 2% in Bencox group and 1% in Pinnacle Incidence of squeaking group. Additionally, there was no squeaking case The demographic analysis showed that the mean age of reported when other brands of acetabular cup (Link, all included cases was 53.35 years, and the mean BMI Biomet, Wlink, and Corin) were applied. The results was 26.73 kg/m (Table 1). A total of 133 cases re- were showninFig. 3. ported squeaking, and we finally calculated the squeak- We then analyzed for the femoral stem brands effect. ing incidence nearly to be 3% (I =87%) (Fig. 1). We Results showed that the occurrence rate of squeaking also did regression analysis to establish the influence of with the presence of Secure-Fit stem was 14%, signifi- patient factors and surgical factors on squeaking. Re- cantly higher than that with the other brands of stems sults showed that age (P =0.50), gender (P =0.73), BMI (P < 0.001). Among patients applying the DePuy stems, (P =0.46), and abduction (P = 0.61) and anteversion the squeak incidence was 7% with the DePuy Summit angles (P = 0.81) of acetabular cup had no significant stem, but only 1% with the DePuy Corail stem, and no effect on the occurrence of squeaking (Table 2). squeaking case was reported with the DePuy Srom stem. Moreover, we divided the studies into two subgroups The occurrence rate was 2% with the presence of based on follow-up time (less than 5-year follow-up Bencox stem; no squeak case was reported when the group, more than or equal to 5-year follow-up group). other brands of stems (Link, Wlink, and Corin) were ap- We revealed that squeaking incidence has no signifi- plied (Fig. 4). cant difference between the two subgroups (P =0.35, Fig. 2). In addition, 32 patients suffered from postop- erative dislocation; the rate of dislocation was ap- Quality assessment and publication bias proximately 1%. Most of the included studies had a moderate score in the methodological quality assessment, and the mean Squeaking and prosthetic brands score was 14.3 (10–18), which meant the included stud- We performed subgroup analysis based on the pros- ies were of relative moderate quality. Although funnel thetic brands to study its impact on squeaking. Firstly, plots showed a certain degree of publication bias, the we analyzed for the acetabular brands’ effect. We found sensitivity analysis demonstrated that our pooled results that the occurrence rate of squeaking in Delta Motion were robust and reliable (Additional file 2: Figure S2). Table 1 Studies included in the meta-analysis Author Year Country Total Patients with Acetabular cup Femoral stem Mean follow-up hips squeak time (months) Cai et al. 2012 China 43 0 NA NA 39.7 McDonnell et al. 2013 Australia 208 26 Delta Motion (DePuy) Finsbury Type C (Finsbury Orthopaedics)/SL 21 Plus MIA stem (Smith & Nephew)/Tri-Lock and Corail (DePuy) Wang et al. 2014 China 177 2 Pinnacle (DePuy) Corail and Summit (DePuy) 12 Hamilton et al. 2015 Canada 345 26 Pinnacle (DePuy) AML, Prodigy, Summit, Srom, and Corail 64 (DePuy) Aoude et al. 2015 Canada 133 1 Pinnacle (DePuy) Corail, SROM, Summit, Trilock and Prodigy 72 (DePuy) Baek et al. 2015 Korea 94 0 Bencox (Corentec) Bencox (Corentec) 60 Kim et al. 2016 Korea 334 2 Pinnacle (DePuy) Proxima (DePuy) 157.2 Lee et al. 2016 Korea 269 0 Exceed eABT™ (Biomet) Taperloc (Biomet) 24 Lim et al. 2016 Korea 53 1 Bencox (Corentec) Bencox (Corentec) 64 Buttaro et al. 2016 Argentina 939 1 Pinnacle (DePuy)/Combi Corail, SROM and Cstem (DePuy)/CFP 64 (Wlink)/Trinity (Corin) (Wlink)/Minihip (Corin) Boden et al. 2017 UK 266 2 Pinnacle (DePuy) Corail (DePuy) 18 Salo et al. 2017 Finland 336 37 Continuum (Zimmer)/Exceed ML Taper (Zimmer)/Bimetric (Biomet)/Corail, 25.6 (Biomet)/Pinnacle (DePuy) Srom, and Summit (DePuy) Goldhofer et al. 2017 Australia 206 15 Delta Motion (DePuy) Secur-Fit stem (Stryker) 60 Lee et al. 2017 Korea 286 7 Pinnacle (DePuy) Proxima (DePuy) 66.5 Zhao et al. Journal of Orthopaedic Surgery and Research (2018) 13:133 Page 4 of 9 2 2 Fig. 1 Forest plots for squeaking incidence of all included studies. I , τ , and P value are tested for heterogeneity Discussion bearing. Thus, we did this systematical study and found We did the first meta-analysis to study the squeaking the occurrence rate was 3%. Previous study has shown incidence in the fourth-generation ceramic bearing. We that the occurrence rate in the third-generation ceramic found that the occurrence rate of squeaking in patients bearing fluctuated at 0.7–20.9% [32]. Stanat and Capozzi who applied the fourth-generation ceramic bearing in conducted the meta-analysis for the studies which mainly primary total hip replacement was nearly 3%. The pres- applied the third-generation ceramic bearing and reported ence of DePuy Delta Motion cup significantly increased the squeaking incidence was 2.4% [33]. It seems that the the incidence of squeaking, and so did the Secure-Fit fourth-generation ceramic bearing does not have a signifi- femoral stem. Age, gender, BMI, and anteversion and cant superiority in postoperative squeaking. abduction angles of acetabular cup were not found to be The mechanisms of postoperative squeaking have not associated with squeaking. There was no significant been clearly elucidated at present; many theories have difference of the squeaking incidence between less than been put forward with the desire to make a comprehen- 5-year and more than or equal to 5-year follow-up sive explanation, including edge loading, lubrication subgroups. imbalance, rim impingement, micro-separation, and The fourth-generation ceramic bearing was first applied stripe wear [6, 7]. The prosthetic factors were accepted in clinical at 2000 [28]; Yang et al. once proposed that im- to be an important part; the designs and materials were provement of material properties may reduce the risk for different in various brands of prosthesis, or in the same squeaking [30], and there was indeed no report of squeak brand but different types of prosthesis [9, 34]. For in the fourth-generation ceramic bearing in the early study instance, the Stryker Trident PSL cup had an elevated [31], but Buttaro et al. presented the first case who suf- rim to increase the ceramic stabilization but caused fered from postoperative squeaking in 2012 [5]. Since more squeaking for impingement between femoral neck then, more and more researches began to declare squeak- and cup [35]; the design of Delta Motion cup did not ing as a complication of the fourth-generation ceramic permit reinforcement by auxiliary screws, which might impact implant stability under specific conditions and be a potential risk for squeaking [36]. Moreover, surgi- cal techniques were connected to squeaking. Incorrect Table 2 Meta-regression analysis for the factors affecting the acetabular cup orientation could cause rim impinge- squeaking incidence ment and edge loading [37]. The patient’sfactorsalso Variables Total hip Study P value 95% CI counted; reports showed that younger, taller, and more Age 3689 14 0.498 − 0.430 to 0.223 active patients may be easier to suffer hip squeaking Gender 3689 14 0.727 − 15.57 to 21.62 [38]. And preoperative diagnosis of rheumatoid arthritis BMI 2145 10 0.464 − 1.935 to 0.967 might be a risk factor for squeaking [10]. Abduction 1537 7 0.606 − 0.889 to 1.415 In our study, the presence of DePuy Delta Motion Anteversion 1494 6 0.817 − 1.309 to 1.584 cup significantly increased squeak. Delta Motion was a BMI body mass index, CI confidence interval pre-assembled cup with large-diameter femoral heads, Zhao et al. Journal of Orthopaedic Surgery and Research (2018) 13:133 Page 5 of 9 2 2 Fig. 2 Forest plots for squeaking incidence in less than 5-year and more than or equal to 5-year follow up groups. I , τ , and P value are tested for heterogeneity which was engineered to maximize head-neck ratios the amplitude, and further amplify the initial vibration and reduce the risk for impingement, thus decreased [15]. In addition, McDonnell pointed out that soft tissue the possibility of squeak [20]. However, it did not laxity and a wider range of movement may provide achieve the intended purpose. In fact, the technology supportive environment for squeaking among patients advancement of the fourth-generation ceramic reduced applying Delta Motion [20]. Combination of the above the thickness of bearing and promoted the application effects might be responsible for the significant higher of large-diameter femoral heads. Large-diameter fem- incidence of squeak in Delta Motion cup. oral heads could reduce joint instability and give pa- Femoral stem design and metallurgical technology also tients a similar sense of movement to healthy subjects have a great impact on squeak. Studies have reported [39, 40], which has become increasingly popular in hip that the Stryker Accolade femoral stem was prone to replacement. However, it might cause micro-separation generate squeak [10, 33]. In the fourth-generation cer- during movement because of the small opening angle amic bearing, only one study reported the application between femoral head and acetabular cup [41]. More- of Stryker femoral stem (Secure-Fit); it had the highest over, if the acetabular cup was too vertical, large fem- incidence of squeak in all the used stems, and this may oral head would significantly increase the load on its be related to the unique design of Stryker femoral stem edge [42]. Micro-separation and edge loading are two (high rim and short neck) [9]. But Secure-Fit femoral critical mechanisms for squeaking. stem had a relatively wider neck with thick long stem Moreover, we know that squeak originates from ir- compared to the Accolade femoral stem [6, 15], and it regular vibrations, which are resulted from the com- was made of Ti-6Al-4V, which has lower tensile proper- bined effects of initial pulse, vibration propagation, and ties and flexibility than Ti-12Mo-6Zr-2Fe (Accolade amplification [43]. The DePuy Delta Motion cup with femoral stem), so it was not conducive to adhere to the larger femoral head might significantly increase the ar- femur, resulting abrasion and lubrication imbalance ticulation surface and frictional moment at the inad- and then causing squeak [35, 45]. Therefore, we specu- equately lubricated condition, thus inducing vibration lated it was highly possible that the high incidence was [44]. And they might increase the prosthesis mass, which attributed to the combinative use of Delta Motion cup, could reduce the natural frequency of vibration, increase but the specific link need to be further explored. Zhao et al. Journal of Orthopaedic Surgery and Research (2018) 13:133 Page 6 of 9 2 2 Fig. 3 Forest plots for squeaking incidence in each subgroup based on acetabular cup brands. I , τ , and P value are tested for heterogeneity In addition, the occurrence rate of squeak with the were applied in the surgery. Different surgical approaches presence of Summit stem was high, but the applied pa- had different effects on soft tissue and affect joint stability tients’ number was small; our conclusion still required [48], which might induce squeaking. As for surgical indi- further verification. cations, study has shown that rheumatoid arthritis was We also conducted regression analysis for age, gender, related with squeaking [10]. Different indications had BMI, acetabular cup abduction and anteversion angle; different surgical requirements, and patients’ basic condi- these factors have no significance for squeak, and the re- tions were also different, which might have potential sults were consistent with previous studies [33, 46]. Lee effects on squeaking. Our research was limited to the fac- [46] once pointed out that abduction angle of acetabular tors such as data amounts and the designs of the study; it cup was a risk factor for squeak, but his research was was difficult to make further assessment. In the future, limited to the Asian population, different from ours. clinical data based on large sample sizes and multi-centers Furthermore, dislocation, exposure types, and surgi- can help to establish the specific effects of these factors on cal indications might have effects on squeaking. Dis- squeaking. location often had similar risk factors for squeaking, The high heterogeneity was a limitation of our including improperly placed prosthesis, unreasonable meta-analysis. We found the high heterogeneity mainly prosthesis design, and soft tissue laxity. Excessive or in- distributed in studies applied the DePuy Pinnacle cup sufficient anteversion of acetabular cup were important and the DePuy Corail femoral stem. These two pros- reasons for dislocation [47], which might not only theses are currently most widely used; studies from dif- causeanincreasingloadonthe cupedge, butalsolead ferent regions and populations were included in our to rim impingement. In our included studies, posterolat- analysis, while studies that applied other types of prostheses eral, posterior, direct lateral, and anterolateral approaches almost came from the same countries and populations. Zhao et al. Journal of Orthopaedic Surgery and Research (2018) 13:133 Page 7 of 9 2 2 Fig. 4 Forest plots for squeaking incidence in each subgroup based on femoral stem brands. I , τ , and P value are tested for heterogeneity Thus, we supposed the high heterogeneity may be due to future. Secondly, some available articles applied a variety of this. Our research still has some other limitations. Firstly, brands of prostheses but did not report the corresponding studies included were mainly on the issue of squeaking, brands of prostheses with squeaking; removing these litera- and the data was all retrieved from the published litera- tures during subgroup analysis might have an influence on tures; these might cause selection or publication bias, and results. Thirdly, the reported studies about squeaking gen- strictly designed and high-quality RCTs are needed in the erated in the fourth-generation ceramic bearing is limited; Zhao et al. Journal of Orthopaedic Surgery and Research (2018) 13:133 Page 8 of 9 our findings require to be further supported by larger num- 3. Cai YZ, Yan SG. Development of ceramic-on-ceramic implants for total hip arthroplasty. Orthop Surg. 2010;2(3):175–81. https://doi.org/10.1111/j.1757- ber of cases and more long-term follow-up studies. 7861.2010.00083.x. 4. Massin P, Lopes R, Masson B, Mainard D, French H, Knee S. Does Biolox Delta ceramic reduce the rate of component fractures in total hip Conclusion replacement? Orthopaedics & traumatology, surgery & research: OTSR. 2014; In conclusion, the overall incidence of squeaking in the 100(6 Suppl):S317–21. https://doi.org/10.1016/j.otsr.2014.05.010. fourth-generation ceramic bearing was nearly 3% in our 5. Buttaro MA, Zanotti G, Comba FM, Piccaluga F. Squeaking in a Delta study. Among the prostheses we studied, the occurrence ceramic-on-ceramic uncemented total hip arthroplasty. J Arthroplast. 2012; 27(6):1257–9. https://doi.org/10.1016/j.arth.2012.01.005. rate was highest with the presence of Delta Motion cup, 6. Levy YD, Munir S, Donohoo S, Walter WL. Review on squeaking hips. World which might be attributed to the increased frictional mo- journal of orthopedics. 2015;6(10):812–20. https://doi.org/10.5312/wjo.v6.i10.812. ment and induction and amplification of initial vibration. 7. Owen D, Russell N, Chia A, Thomas M. The natural history of ceramic-on- ceramic prosthetic hip squeak and its impact on patients. European journal Age, gender, BMI, and other related factors might have no of orthopaedic surgery & traumatology: orthopedie traumatologie. 2014; significant effect on squeaking in the fourth-generation 24(1):57–61. https://doi.org/10.1007/s00590-012-1142-5. ceramic bearing. Finally, we look forward to more relevant 8. Abdel MP, Heyse TJ, Elpers ME, Mayman DJ, Su EP, Pellicci PM, et al. Ceramic liner fractures presenting as squeaking after primary total hip researches focusing on this issue. arthroplasty. J Bone Joint Surg Am. 2014;96:27–31. 9. Wu GL, Zhu W, Zhao Y, Ma Q, Weng XS. Hip squeaking after ceramic-on- ceramic total hip arthroplasty. Chin Med J. 2016;129(15):1861–6. https://doi. Additional files org/10.4103/0366-6999.186654. 10. Swanson TV, Peterson DJ, Seethala R, Bliss RL, Spellmon CA. Influence of Additional file 1: Figure S1. Flowchart of literature selection. (TIF 701 kb) prosthetic design on squeaking after ceramic-on-ceramic total hip Additional file 2: Figure S2. Sensitivity analysis of the study. (TIF 340 kb) arthroplasty. J Arthroplast. 2010;25(6 Suppl):36–42. https://doi.org/10.1016/j. arth.2010.04.032. 11. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting Abbreviation items for systematic reviews and meta-analyses: the PRISMA statement. BMI: Body mass index J Clin Epidemiol. 2009;62(10):1006–12. https://doi.org/10.1016/j.jclinepi. 2009.06.005. Acknowledgements 12. Moher D, Schulz KF, Altman DG. The CONSORT statement: revised We thank all the authors of the included literatures for their contribution to recommendations for improving the quality of reports of parallel-group our systematic review. And we thank the National Natural Science randomised trials. Lancet. 2001;357(9263):1191–4. Foundation of China for the support of this work. 13. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557–60. https://doi.org/10.1136/bmj.327. Funding 7414.557. This work was supported by the National Natural Science Foundation of 14. Stafford GH, Islam SU, Witt JD. Early to mid-term results of ceramic-on- China (81472113). ceramic total hip replacement: analysis of bearing-surface-related complications. The Journal of bone and joint surgery British volume. 2011; Availability of data and materials 93(8):1017–20. https://doi.org/10.1302/0301-620X.93B8.26505. The data of the manuscript was presented in the paper and supplemental files. 15. Tai SM, Munir S, Walter WL, Pearce SJ, Walter WK, Zicat BA. Squeaking in large diameter ceramic-on-ceramic bearings in total hip arthroplasty. J Authors’ contributions Arthroplast. 2015;30(2):282–5. https://doi.org/10.1016/j.arth.2014.09.010. XZC contributed to the design of the experiments, extracted and analyzed 16. Aoude AA, Antoniou J, Epure LM, Huk OL, Zukor DJ, Tanzer M. Midterm data, and wrote the manuscript. CCZ contributed to the retrieval of the outcomes of the recently FDA approved ceramic on ceramic bearing in literatures, extracted and analyzed data, and wrote the manuscript. GXQ Total hip arthroplasty patients under 65 years of age. J Arthroplast. 2015; contributed to the retrieval of the literatures and extracted and analyzed 30(8):1388–92. https://doi.org/10.1016/j.arth.2015.03.028. data. And SGY participated in designing the experiments. All authors listed 17. Hamilton WG,McAuley JP,BlumenfeldTJ,Lesko JP,Himden SE, read and approved the final manuscript. Dennis DA. Midterm results of Delta ceramic-on-ceramic total hip arthroplasty. J Arthroplast. 2015;30(9 Suppl):110–5. https://doi.org/10. 1016/j.arth.2015.02.047. Ethics approval and consent to participate 18. Kim YH, Park JW, Kim JS. Alumina Delta-on-alumina Delta bearing in Not applicable. cementless total hip arthroplasty in patients aged < 50 years. J Arthroplast. 2016;31(10):2209–14. https://doi.org/10.1016/j.arth.2016.03.016. Competing interests 19. Buttaro MA, Zanotti G, Comba FM, Piccaluga F. Primary total hip The authors declare that they have no competing interests. arthroplasty with fourth-generation ceramic-on-ceramic: analysis of complications in 939 consecutive cases followed for 2-10 years. J Publisher’sNote Arthroplast. 2017;32(2):480–6. https://doi.org/10.1016/j.arth.2016.07.032. Springer Nature remains neutral with regard to jurisdictional claims in 20. McDonnell SM, Boyce G, Bare J, Young D, Shimmin AJ. The incidence of published maps and institutional affiliations. noise generation arising from the large-diameter Delta Motion ceramic total hip bearing. The bone & joint journal. 2013;95-B(2):160–5. https://doi.org/10. Received: 1 March 2018 Accepted: 21 May 2018 1302/0301-620X.95B2.30450. 21. Goldhofer MI, Munir S, Levy YD, Walter WK, Zicat B, Walter WL. 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The Journal of bone and joint surgery British volume. 2011;93(7): 876–80. https://doi.org/10.1302/0301-620X.93B7.26657. 40. Szymanski C, Thouvarecq R, Dujardin F, Migaud H, Maynou C, Girard J. Functional performance after hip resurfacing or total hip replacement: a comparative assessment with non-operated subjects. Orthopaedics & traumatology, surgery & research: OTSR. 2012;98(1):1–7. https://doi.org/10. 1016/j.otsr.2011.10.006. 41. Burroughs BR, Hallstrom B, Golladay GJ, Hoeffel D, Harris WH. Range of motion and stability in total hip arthroplasty with 28-, 32-, 38-, and 44-mm femoral head sizes. J Arthroplast. 2005;20(1):11–9. https://doi.org/10.1016/j. arth.2004.07.008. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Orthopaedic Surgery and Research Springer Journals

Squeaking in fourth-generation ceramic-on-ceramic total hip replacement and the relationship with prosthesis brands: meta-analysis and systematic review

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Medicine & Public Health; Orthopedics; Surgical Orthopedics
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Abstract

Background: Postoperative squeaking in patients who applied the fourth-generation ceramic bearing in primary hip replacement has not been reported systematically; we aim to study the squeaking incidence in the fourth- generation ceramic bearing and related risk factors for squeaking, and we also attempt to explore the relationship between squeaking and prosthetic brands. Methods: The PubMed, Embase, and Cochrane library were searched, and 14 articles were finally included. Patients’ demographic data, surgical-related information, and prosthesis data were extracted. The occurrence rate of squeaking was calculated by meta-analysis, and subgroup analysis was performed based on prosthetic brands and follow-up time. Regression analysis was further applied to investigate the relationship between various risk factors and squeaking. Results: The squeaking incidence in patients with the fourth-generation ceramic bearing was 3%. Age, gender, body mass index, and abduction and anteversion angles of acetabular cup might have no influence on squeaking. The squeaking incidence was significantly high with the presence of Delta Motion cup (DePuy, Warsaw, Indiana) and Secure-Fit stem (Stryker, Kalamazoo, MI), and the overall incidence of DePuy femoral stem was relatively small except for the Summit femoral stem. And there was no significant difference of squeaking incidence between less than 5-year and more than or equal to 5-year follow-up subgroups. Conclusions: In our study, squeaking in the fourth-generation ceramic bearing occurred at a rate of 3%; occurrence rate was high when the Delta Motion cup was applied. We hope for more relevant researches to focus on this issue. Keywords: Squeaking, Fourth-generation ceramics, Total hip replacement, Prosthesis brands Background many years. Compared with the third generation, it Ceramic-on-ceramic bearing has been widely applied in added zirconia (18%), chromium oxide (< 1%), and total hip replacement for the biological inert, well wear- strontium oxide (< 1%) on the basis of alumina [3]. The ing capacity, and low inflammatory reaction caused by addition of these components reduced the risk for pros- wear particles [1, 2]. The fourth-generation ceramic thesis fracture [4], however, still could not get rid of bearing (BIOLOX Delta, CeramTec AG, Plochingen, squeaking [5]. Germany) has been used in total hip replacement for Squeaking was a high-pitched and audible sound, which was considered as a unique but unavoidable phenomenon in hard-on-hard bearing interface [6]. It * Correspondence: 2506053@zju.edu.cn; emilcai@163.com often appeared in painless or infrequent forms, but their Department of Orthopaedic Surgery, Second Affiliated Hospital of Zhejiang persistence might reduce patient satisfaction, or even University School of Medicine, Jiefang Road 88, Hangzhou 310009, China Orthopaedic Research Laboratory, Zhejiang University, Jiefang Road 88, cause revision surgery [7]. What is more, it also could be Hangzhou, China © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Zhao et al. Journal of Orthopaedic Surgery and Research (2018) 13:133 Page 2 of 9 an early sign of pressure peaks indicating incongruency Data extraction and a risk factor for component breakage [8]. Three authors (CCZ, GXQ, and XZC) retrieved the in- The mechanisms of squeaking were not yet fully cluded articles and extracted relevant data independently; understood; prosthesis factors have been regarded as an disagreements were resolved by discussion. Country of important contributor [6, 9]. There has been a study study, publication year, total number of patients, number comparing four kinds of femoral stems and a finding of patients with squeaking, and mean follow-up time were that the presence of Accolade femoral stem (Stryker, obtained. Moreover, patients’ demographic data (age and Mahwah, NJ) was significantly associated with hip gender) and body mass index (BMI) were collected, and in squeaking [10]. Indeed, different brands of prostheses some studies, BMI was indirectly calculated based on or different types of prosthesis with the same brand weight and height. Surgical information included the ab- had various designs and materials; we surmised that duction and anteversion angles of the acetabular cup squeaking incidence might be different when different which were identified by computerized tomography were types of prostheses were used. also abstracted. And above all, the brands of acetabular To our knowledge, there was no meta-analysis to cup and femoral stem were extracted. determine the occurrence rate of squeaking in the fourth generation of ceramic-on-ceramic total hip replacement. Quality assessment We aimed to explore the occurrence rate of squeaking The assessment of the methodological quality of each in the fourth generation of ceramic-on-ceramic total hip study was performed with the Consolidated Standards of replacement. The second purpose was to determine the Reporting Trials checklist [12]. Each study was scored risk factors for squeaking. Moreover, we also attempted by two of the authors (ZCC and QGX) based on the to observe the occurrence rate in different prosthetic scale, in which 22 questions were presented and the brands and find the possible relationship between squeak- score was 1 for “Yes” and 0 for “No or unclear.” The ing and prosthetic brands. disagreements were resolved by discussion. Methods Statistical analysis Search strategy We used the R software for statistical analysis. The results This meta-analysis was completed in accordance with were presented as weighted mean difference with 95% the reported guidelines [11]. The PubMed, Embase, and confidence interval or mean values. Incidence of squeak Cochrane library were searched before 22 January 2018 (p) was calculated by total hips (n) and the number of hips by using the following strategy: “hip and ceramic,”“hip with squeak (x)(if np > 5 and n (1 − p) > 5, then p = x/n, and squeak,”“hip and squeaking,”“hip and noise,”“hip SE (p)= √p (1 − p)/n;if np <5 or n (1 − p) < 5, then p =ln and sound,”“arthroplasty and squeak,”“arthroplasty and (x/(n − x)), SE(p)= √1/x +1/(n − x). Heterogeneity between squeaking,”“arthroplasty and noise,”“arthroplasty and the included studies was evaluated by the Q statistic, τ , sound,”“arthroplasty and ceramic,”“squeak and delta,” and I statistic [13], and the fixed effect model would be and “squeaking and delta.” The results were combined, applied if P > 0.1 and I < 50%; otherwise, the random and the repeated publications were excluded; only English effect model would be used (P < 0.1 and I > 50%). Sensi- language and human studies with full text available were tivity analysis was further conducted to assess the robust- included. When several publications from the same study ness and reliability of the pooled results. The publication population were found, the most recent or most detailed bias was evaluated by funnel plots. All results were pre- one was chosen in our analysis. sented in the form of forest plots, and P values less than 0.05 was considered statistically significant. Selection criteria The title and abstract of the literatures were reviewed by two of the authors (CCZ and GXQ). After a preliminary Results screening, we read the full text that possibly met the cri- Search results teria. Studies were included according to the following cri- We conducted the search based on the mentioned key- teria: (1) underwent primary total hip replacement, (2) words and initially identified 3516 relevant articles. After applied the fourth-generation ceramic bearing, (3) clearly reviewing the titles and abstracts, 114 articles were further reported the prosthetic brands, (4) reported squeak or evaluated for eligibility. Then, we found 17 articles might noise as an outcome or complication, and (5) randomized satisfy the inclusion criteria through full text reading, but controlled trials and cohort or cross-sectional studies. one did not explicitly report the patients’ number using Literatures which have not specifically point out whether the fourth-generation ceramics [14], and one got conclu- the third or fourth generation of ceramic bearing applied sions from the same population [15], and one was a case were excluded. report [5]. Finally, the remaining 14 articles were included Zhao et al. Journal of Orthopaedic Surgery and Research (2018) 13:133 Page 3 of 9 for meta-analyses [16–29]. The flowchart of literature se- group was as high as 13%, significantly higher than that lection was shown in Additional file 1: Figure S1. in the other three groups (P < 0.001). The squeaking incidence was 2% in Bencox group and 1% in Pinnacle Incidence of squeaking group. Additionally, there was no squeaking case The demographic analysis showed that the mean age of reported when other brands of acetabular cup (Link, all included cases was 53.35 years, and the mean BMI Biomet, Wlink, and Corin) were applied. The results was 26.73 kg/m (Table 1). A total of 133 cases re- were showninFig. 3. ported squeaking, and we finally calculated the squeak- We then analyzed for the femoral stem brands effect. ing incidence nearly to be 3% (I =87%) (Fig. 1). We Results showed that the occurrence rate of squeaking also did regression analysis to establish the influence of with the presence of Secure-Fit stem was 14%, signifi- patient factors and surgical factors on squeaking. Re- cantly higher than that with the other brands of stems sults showed that age (P =0.50), gender (P =0.73), BMI (P < 0.001). Among patients applying the DePuy stems, (P =0.46), and abduction (P = 0.61) and anteversion the squeak incidence was 7% with the DePuy Summit angles (P = 0.81) of acetabular cup had no significant stem, but only 1% with the DePuy Corail stem, and no effect on the occurrence of squeaking (Table 2). squeaking case was reported with the DePuy Srom stem. Moreover, we divided the studies into two subgroups The occurrence rate was 2% with the presence of based on follow-up time (less than 5-year follow-up Bencox stem; no squeak case was reported when the group, more than or equal to 5-year follow-up group). other brands of stems (Link, Wlink, and Corin) were ap- We revealed that squeaking incidence has no signifi- plied (Fig. 4). cant difference between the two subgroups (P =0.35, Fig. 2). In addition, 32 patients suffered from postop- erative dislocation; the rate of dislocation was ap- Quality assessment and publication bias proximately 1%. Most of the included studies had a moderate score in the methodological quality assessment, and the mean Squeaking and prosthetic brands score was 14.3 (10–18), which meant the included stud- We performed subgroup analysis based on the pros- ies were of relative moderate quality. Although funnel thetic brands to study its impact on squeaking. Firstly, plots showed a certain degree of publication bias, the we analyzed for the acetabular brands’ effect. We found sensitivity analysis demonstrated that our pooled results that the occurrence rate of squeaking in Delta Motion were robust and reliable (Additional file 2: Figure S2). Table 1 Studies included in the meta-analysis Author Year Country Total Patients with Acetabular cup Femoral stem Mean follow-up hips squeak time (months) Cai et al. 2012 China 43 0 NA NA 39.7 McDonnell et al. 2013 Australia 208 26 Delta Motion (DePuy) Finsbury Type C (Finsbury Orthopaedics)/SL 21 Plus MIA stem (Smith & Nephew)/Tri-Lock and Corail (DePuy) Wang et al. 2014 China 177 2 Pinnacle (DePuy) Corail and Summit (DePuy) 12 Hamilton et al. 2015 Canada 345 26 Pinnacle (DePuy) AML, Prodigy, Summit, Srom, and Corail 64 (DePuy) Aoude et al. 2015 Canada 133 1 Pinnacle (DePuy) Corail, SROM, Summit, Trilock and Prodigy 72 (DePuy) Baek et al. 2015 Korea 94 0 Bencox (Corentec) Bencox (Corentec) 60 Kim et al. 2016 Korea 334 2 Pinnacle (DePuy) Proxima (DePuy) 157.2 Lee et al. 2016 Korea 269 0 Exceed eABT™ (Biomet) Taperloc (Biomet) 24 Lim et al. 2016 Korea 53 1 Bencox (Corentec) Bencox (Corentec) 64 Buttaro et al. 2016 Argentina 939 1 Pinnacle (DePuy)/Combi Corail, SROM and Cstem (DePuy)/CFP 64 (Wlink)/Trinity (Corin) (Wlink)/Minihip (Corin) Boden et al. 2017 UK 266 2 Pinnacle (DePuy) Corail (DePuy) 18 Salo et al. 2017 Finland 336 37 Continuum (Zimmer)/Exceed ML Taper (Zimmer)/Bimetric (Biomet)/Corail, 25.6 (Biomet)/Pinnacle (DePuy) Srom, and Summit (DePuy) Goldhofer et al. 2017 Australia 206 15 Delta Motion (DePuy) Secur-Fit stem (Stryker) 60 Lee et al. 2017 Korea 286 7 Pinnacle (DePuy) Proxima (DePuy) 66.5 Zhao et al. Journal of Orthopaedic Surgery and Research (2018) 13:133 Page 4 of 9 2 2 Fig. 1 Forest plots for squeaking incidence of all included studies. I , τ , and P value are tested for heterogeneity Discussion bearing. Thus, we did this systematical study and found We did the first meta-analysis to study the squeaking the occurrence rate was 3%. Previous study has shown incidence in the fourth-generation ceramic bearing. We that the occurrence rate in the third-generation ceramic found that the occurrence rate of squeaking in patients bearing fluctuated at 0.7–20.9% [32]. Stanat and Capozzi who applied the fourth-generation ceramic bearing in conducted the meta-analysis for the studies which mainly primary total hip replacement was nearly 3%. The pres- applied the third-generation ceramic bearing and reported ence of DePuy Delta Motion cup significantly increased the squeaking incidence was 2.4% [33]. It seems that the the incidence of squeaking, and so did the Secure-Fit fourth-generation ceramic bearing does not have a signifi- femoral stem. Age, gender, BMI, and anteversion and cant superiority in postoperative squeaking. abduction angles of acetabular cup were not found to be The mechanisms of postoperative squeaking have not associated with squeaking. There was no significant been clearly elucidated at present; many theories have difference of the squeaking incidence between less than been put forward with the desire to make a comprehen- 5-year and more than or equal to 5-year follow-up sive explanation, including edge loading, lubrication subgroups. imbalance, rim impingement, micro-separation, and The fourth-generation ceramic bearing was first applied stripe wear [6, 7]. The prosthetic factors were accepted in clinical at 2000 [28]; Yang et al. once proposed that im- to be an important part; the designs and materials were provement of material properties may reduce the risk for different in various brands of prosthesis, or in the same squeaking [30], and there was indeed no report of squeak brand but different types of prosthesis [9, 34]. For in the fourth-generation ceramic bearing in the early study instance, the Stryker Trident PSL cup had an elevated [31], but Buttaro et al. presented the first case who suf- rim to increase the ceramic stabilization but caused fered from postoperative squeaking in 2012 [5]. Since more squeaking for impingement between femoral neck then, more and more researches began to declare squeak- and cup [35]; the design of Delta Motion cup did not ing as a complication of the fourth-generation ceramic permit reinforcement by auxiliary screws, which might impact implant stability under specific conditions and be a potential risk for squeaking [36]. Moreover, surgi- cal techniques were connected to squeaking. Incorrect Table 2 Meta-regression analysis for the factors affecting the acetabular cup orientation could cause rim impinge- squeaking incidence ment and edge loading [37]. The patient’sfactorsalso Variables Total hip Study P value 95% CI counted; reports showed that younger, taller, and more Age 3689 14 0.498 − 0.430 to 0.223 active patients may be easier to suffer hip squeaking Gender 3689 14 0.727 − 15.57 to 21.62 [38]. And preoperative diagnosis of rheumatoid arthritis BMI 2145 10 0.464 − 1.935 to 0.967 might be a risk factor for squeaking [10]. Abduction 1537 7 0.606 − 0.889 to 1.415 In our study, the presence of DePuy Delta Motion Anteversion 1494 6 0.817 − 1.309 to 1.584 cup significantly increased squeak. Delta Motion was a BMI body mass index, CI confidence interval pre-assembled cup with large-diameter femoral heads, Zhao et al. Journal of Orthopaedic Surgery and Research (2018) 13:133 Page 5 of 9 2 2 Fig. 2 Forest plots for squeaking incidence in less than 5-year and more than or equal to 5-year follow up groups. I , τ , and P value are tested for heterogeneity which was engineered to maximize head-neck ratios the amplitude, and further amplify the initial vibration and reduce the risk for impingement, thus decreased [15]. In addition, McDonnell pointed out that soft tissue the possibility of squeak [20]. However, it did not laxity and a wider range of movement may provide achieve the intended purpose. In fact, the technology supportive environment for squeaking among patients advancement of the fourth-generation ceramic reduced applying Delta Motion [20]. Combination of the above the thickness of bearing and promoted the application effects might be responsible for the significant higher of large-diameter femoral heads. Large-diameter fem- incidence of squeak in Delta Motion cup. oral heads could reduce joint instability and give pa- Femoral stem design and metallurgical technology also tients a similar sense of movement to healthy subjects have a great impact on squeak. Studies have reported [39, 40], which has become increasingly popular in hip that the Stryker Accolade femoral stem was prone to replacement. However, it might cause micro-separation generate squeak [10, 33]. In the fourth-generation cer- during movement because of the small opening angle amic bearing, only one study reported the application between femoral head and acetabular cup [41]. More- of Stryker femoral stem (Secure-Fit); it had the highest over, if the acetabular cup was too vertical, large fem- incidence of squeak in all the used stems, and this may oral head would significantly increase the load on its be related to the unique design of Stryker femoral stem edge [42]. Micro-separation and edge loading are two (high rim and short neck) [9]. But Secure-Fit femoral critical mechanisms for squeaking. stem had a relatively wider neck with thick long stem Moreover, we know that squeak originates from ir- compared to the Accolade femoral stem [6, 15], and it regular vibrations, which are resulted from the com- was made of Ti-6Al-4V, which has lower tensile proper- bined effects of initial pulse, vibration propagation, and ties and flexibility than Ti-12Mo-6Zr-2Fe (Accolade amplification [43]. The DePuy Delta Motion cup with femoral stem), so it was not conducive to adhere to the larger femoral head might significantly increase the ar- femur, resulting abrasion and lubrication imbalance ticulation surface and frictional moment at the inad- and then causing squeak [35, 45]. Therefore, we specu- equately lubricated condition, thus inducing vibration lated it was highly possible that the high incidence was [44]. And they might increase the prosthesis mass, which attributed to the combinative use of Delta Motion cup, could reduce the natural frequency of vibration, increase but the specific link need to be further explored. Zhao et al. Journal of Orthopaedic Surgery and Research (2018) 13:133 Page 6 of 9 2 2 Fig. 3 Forest plots for squeaking incidence in each subgroup based on acetabular cup brands. I , τ , and P value are tested for heterogeneity In addition, the occurrence rate of squeak with the were applied in the surgery. Different surgical approaches presence of Summit stem was high, but the applied pa- had different effects on soft tissue and affect joint stability tients’ number was small; our conclusion still required [48], which might induce squeaking. As for surgical indi- further verification. cations, study has shown that rheumatoid arthritis was We also conducted regression analysis for age, gender, related with squeaking [10]. Different indications had BMI, acetabular cup abduction and anteversion angle; different surgical requirements, and patients’ basic condi- these factors have no significance for squeak, and the re- tions were also different, which might have potential sults were consistent with previous studies [33, 46]. Lee effects on squeaking. Our research was limited to the fac- [46] once pointed out that abduction angle of acetabular tors such as data amounts and the designs of the study; it cup was a risk factor for squeak, but his research was was difficult to make further assessment. In the future, limited to the Asian population, different from ours. clinical data based on large sample sizes and multi-centers Furthermore, dislocation, exposure types, and surgi- can help to establish the specific effects of these factors on cal indications might have effects on squeaking. Dis- squeaking. location often had similar risk factors for squeaking, The high heterogeneity was a limitation of our including improperly placed prosthesis, unreasonable meta-analysis. We found the high heterogeneity mainly prosthesis design, and soft tissue laxity. Excessive or in- distributed in studies applied the DePuy Pinnacle cup sufficient anteversion of acetabular cup were important and the DePuy Corail femoral stem. These two pros- reasons for dislocation [47], which might not only theses are currently most widely used; studies from dif- causeanincreasingloadonthe cupedge, butalsolead ferent regions and populations were included in our to rim impingement. In our included studies, posterolat- analysis, while studies that applied other types of prostheses eral, posterior, direct lateral, and anterolateral approaches almost came from the same countries and populations. Zhao et al. Journal of Orthopaedic Surgery and Research (2018) 13:133 Page 7 of 9 2 2 Fig. 4 Forest plots for squeaking incidence in each subgroup based on femoral stem brands. I , τ , and P value are tested for heterogeneity Thus, we supposed the high heterogeneity may be due to future. Secondly, some available articles applied a variety of this. Our research still has some other limitations. Firstly, brands of prostheses but did not report the corresponding studies included were mainly on the issue of squeaking, brands of prostheses with squeaking; removing these litera- and the data was all retrieved from the published litera- tures during subgroup analysis might have an influence on tures; these might cause selection or publication bias, and results. Thirdly, the reported studies about squeaking gen- strictly designed and high-quality RCTs are needed in the erated in the fourth-generation ceramic bearing is limited; Zhao et al. Journal of Orthopaedic Surgery and Research (2018) 13:133 Page 8 of 9 our findings require to be further supported by larger num- 3. Cai YZ, Yan SG. Development of ceramic-on-ceramic implants for total hip arthroplasty. Orthop Surg. 2010;2(3):175–81. https://doi.org/10.1111/j.1757- ber of cases and more long-term follow-up studies. 7861.2010.00083.x. 4. Massin P, Lopes R, Masson B, Mainard D, French H, Knee S. Does Biolox Delta ceramic reduce the rate of component fractures in total hip Conclusion replacement? Orthopaedics & traumatology, surgery & research: OTSR. 2014; In conclusion, the overall incidence of squeaking in the 100(6 Suppl):S317–21. https://doi.org/10.1016/j.otsr.2014.05.010. fourth-generation ceramic bearing was nearly 3% in our 5. Buttaro MA, Zanotti G, Comba FM, Piccaluga F. Squeaking in a Delta study. Among the prostheses we studied, the occurrence ceramic-on-ceramic uncemented total hip arthroplasty. J Arthroplast. 2012; 27(6):1257–9. https://doi.org/10.1016/j.arth.2012.01.005. rate was highest with the presence of Delta Motion cup, 6. Levy YD, Munir S, Donohoo S, Walter WL. Review on squeaking hips. World which might be attributed to the increased frictional mo- journal of orthopedics. 2015;6(10):812–20. https://doi.org/10.5312/wjo.v6.i10.812. ment and induction and amplification of initial vibration. 7. Owen D, Russell N, Chia A, Thomas M. The natural history of ceramic-on- ceramic prosthetic hip squeak and its impact on patients. European journal Age, gender, BMI, and other related factors might have no of orthopaedic surgery & traumatology: orthopedie traumatologie. 2014; significant effect on squeaking in the fourth-generation 24(1):57–61. https://doi.org/10.1007/s00590-012-1142-5. ceramic bearing. Finally, we look forward to more relevant 8. Abdel MP, Heyse TJ, Elpers ME, Mayman DJ, Su EP, Pellicci PM, et al. Ceramic liner fractures presenting as squeaking after primary total hip researches focusing on this issue. arthroplasty. J Bone Joint Surg Am. 2014;96:27–31. 9. Wu GL, Zhu W, Zhao Y, Ma Q, Weng XS. Hip squeaking after ceramic-on- ceramic total hip arthroplasty. Chin Med J. 2016;129(15):1861–6. https://doi. Additional files org/10.4103/0366-6999.186654. 10. Swanson TV, Peterson DJ, Seethala R, Bliss RL, Spellmon CA. Influence of Additional file 1: Figure S1. Flowchart of literature selection. (TIF 701 kb) prosthetic design on squeaking after ceramic-on-ceramic total hip Additional file 2: Figure S2. Sensitivity analysis of the study. (TIF 340 kb) arthroplasty. J Arthroplast. 2010;25(6 Suppl):36–42. https://doi.org/10.1016/j. arth.2010.04.032. 11. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting Abbreviation items for systematic reviews and meta-analyses: the PRISMA statement. BMI: Body mass index J Clin Epidemiol. 2009;62(10):1006–12. https://doi.org/10.1016/j.jclinepi. 2009.06.005. Acknowledgements 12. Moher D, Schulz KF, Altman DG. The CONSORT statement: revised We thank all the authors of the included literatures for their contribution to recommendations for improving the quality of reports of parallel-group our systematic review. And we thank the National Natural Science randomised trials. Lancet. 2001;357(9263):1191–4. Foundation of China for the support of this work. 13. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557–60. https://doi.org/10.1136/bmj.327. Funding 7414.557. This work was supported by the National Natural Science Foundation of 14. Stafford GH, Islam SU, Witt JD. Early to mid-term results of ceramic-on- China (81472113). ceramic total hip replacement: analysis of bearing-surface-related complications. The Journal of bone and joint surgery British volume. 2011; Availability of data and materials 93(8):1017–20. https://doi.org/10.1302/0301-620X.93B8.26505. The data of the manuscript was presented in the paper and supplemental files. 15. Tai SM, Munir S, Walter WL, Pearce SJ, Walter WK, Zicat BA. Squeaking in large diameter ceramic-on-ceramic bearings in total hip arthroplasty. J Authors’ contributions Arthroplast. 2015;30(2):282–5. https://doi.org/10.1016/j.arth.2014.09.010. XZC contributed to the design of the experiments, extracted and analyzed 16. Aoude AA, Antoniou J, Epure LM, Huk OL, Zukor DJ, Tanzer M. Midterm data, and wrote the manuscript. CCZ contributed to the retrieval of the outcomes of the recently FDA approved ceramic on ceramic bearing in literatures, extracted and analyzed data, and wrote the manuscript. GXQ Total hip arthroplasty patients under 65 years of age. J Arthroplast. 2015; contributed to the retrieval of the literatures and extracted and analyzed 30(8):1388–92. https://doi.org/10.1016/j.arth.2015.03.028. data. And SGY participated in designing the experiments. All authors listed 17. Hamilton WG,McAuley JP,BlumenfeldTJ,Lesko JP,Himden SE, read and approved the final manuscript. Dennis DA. Midterm results of Delta ceramic-on-ceramic total hip arthroplasty. J Arthroplast. 2015;30(9 Suppl):110–5. https://doi.org/10. 1016/j.arth.2015.02.047. Ethics approval and consent to participate 18. Kim YH, Park JW, Kim JS. Alumina Delta-on-alumina Delta bearing in Not applicable. cementless total hip arthroplasty in patients aged < 50 years. J Arthroplast. 2016;31(10):2209–14. https://doi.org/10.1016/j.arth.2016.03.016. Competing interests 19. Buttaro MA, Zanotti G, Comba FM, Piccaluga F. Primary total hip The authors declare that they have no competing interests. arthroplasty with fourth-generation ceramic-on-ceramic: analysis of complications in 939 consecutive cases followed for 2-10 years. J Publisher’sNote Arthroplast. 2017;32(2):480–6. https://doi.org/10.1016/j.arth.2016.07.032. Springer Nature remains neutral with regard to jurisdictional claims in 20. McDonnell SM, Boyce G, Bare J, Young D, Shimmin AJ. The incidence of published maps and institutional affiliations. noise generation arising from the large-diameter Delta Motion ceramic total hip bearing. The bone & joint journal. 2013;95-B(2):160–5. https://doi.org/10. Received: 1 March 2018 Accepted: 21 May 2018 1302/0301-620X.95B2.30450. 21. Goldhofer MI, Munir S, Levy YD, Walter WK, Zicat B, Walter WL. 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Journal of Orthopaedic Surgery and ResearchSpringer Journals

Published: Jun 1, 2018

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