Squeaking Hip Implants

AP pelvis radiograph of a ceramic on ceramic total hip replacement
Standing AP pelvis of a ceramic on ceramic total hip replacement in a patient who presented with a painless squeak. Component position on films and CT is the first step in working up a squeaking hip. Image from Bellity J, Elkaïm M, Hannouche D, Nizard R. Arthroscopic evaluation and treatment of a squeaking hip. A case report. BMC Musculoskelet Disord. 2020, 21(1), 805. CC BY 4.0.

Overview

  • High pitched noise, mostly with ceramic on ceramic bearings
  • Pooled rates about 2 to 3% in ceramic on ceramic THR, varying with implant design
  • Edge loading, stripe wear, lost fluid film, third body particles and stem resonance
  • Younger, more active, taller and heavier patients at higher risk
  • Most squeaking is painless and needs no surgery
  • Revise for persistent distressing noise, malposition, ceramic fracture or impingement

Epidemiology

  • Mainly ceramic on ceramic, also metal on metal and resurfacing
  • Pooled incidence about 2 to 3% in ceramic on ceramic THR, varying with implant design
  • Appears months to years postoperatively

Aetiology

  • Edge loading causes stripe wear, loss of fluid film lubrication and dry friction
  • Excess cup inclination or abnormal version increases edge loading
  • Neck to rim impingement transfers metal onto ceramic
  • Certain stem alloys and elevated metal rim cups, possibly altering resonance
  • Younger, taller, heavier and more active patients

Clinical Features

  • Clicking suggests instability, liner problems or iliopsoas snapping
  • Grinding raises concern for ceramic fracture
  • Clunking suggests subluxation or loosening

Investigations

  • Radiographs for position, loosening, osteolysis and ceramic fragments
  • CT for version and fracture fragments
  • Metal ions with metal transfer or metal bearings

Management

  • Painless intermittent squeak, reassurance and activity modification
  • Squeak alone does not imply early failure
  • Revise for ceramic fracture, pain, instability, malposition or intolerable noise
  • Correct cup malposition and impingement, and exchange to ceramic on highly cross-linked polyethylene
  • After ceramic fracture, synovectomy and a new ceramic head, never metal
  • Titanium sleeved ceramic head on a damaged trunnion
  • Revision for squeak alone may not abolish the noise
  • Prevent with accurate cup positioning and avoidance of impingement

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 11 October 2026.