title: Hard-on-Hard Bearings Are Associated With Increased Noise Generation in Young Patients Undergoing Hip Arthroplasty.
abstract: BACKGROUND
  Patient-perceived noise from prostheses after total hip arthroplasty (THA) does occur, yet questions remain including the overall frequency of this finding, demographic and prosthesis-related factors, and the association of noise generation with patient-reported outcomes.
  
  
  OBJECTIVE
  The purposes of this study were (1) to determine the frequency with which patients report noise coming from the hip after THA; (2) to identify patient and prosthesis-related factors associated with noise generation; and (3) to ascertain if noise generation is associated with pain or functional impairment after THA.
  
  
  METHODS
  A five-center study was designed to quantify the degree of residual symptoms and functional deficits in patients undergoing THA. Three centers were academic practices, whereas two centers were private practices that provided training programs for orthopaedic residents and fellows. Each contributing surgeon was fellowship-trained and specialized in joint replacement. Inclusion criteria for this study were (1) men between 18 and 60 years old and women between 18 and 55 years old; (2) patients requiring primary hip surgery as a result of noninflammatory arthritis such as osteoarthritis, traumatic arthritis, or avascular necrosis; (3) a UCLA activity score of 6 or more before they were limited by pain; and (4) patients who had undergone a primary THA within 1 to 4 years before the start of the study and had a minimum of 1 year of clinical followup. Attempts were made to contact all identified patients meeting these inclusion criteria. Data were collected by an independent, third-party survey center blinded to the implant design and bearing surface used who administered questionnaires about residual symptoms, function, and pre- and postoperative activity levels using previously published survey instruments. Patients were specifically queried regarding perceived noise from their THA. We retrospectively identified 1242 eligible patients. Of the 1242 patients, 105 were found to have exclusions during the screening section of the questionnaire: postoperative infection (six THAs), fracture (two), dislocation (seven), or revision (17); limited activity level because of an operation on the opposite hip (34); and premorbid UCLA score of less than 6 (39). In addition, 128 individuals refused to participate, 156 were never available, 108 were not found as a result of a bad address/phone number, 48 were contacted but did not complete the interview, nine had died, and six had a language barrier. This left 682 of the 1137 eligible patients with completed surveys (60% response rate). The mean age was 50 ± 8 years at the time of surgery with 63% being men, and they were contacted at a mean of 3 ± 1 years postoperatively. Bearing surfaces (femoral head-acetabular liner) included 210 (31%) metal-on-metal, 144 (21%) ceramic-on-ceramic, 142 (21%) ceramic-on-polyethylene, 141 (21%) cobalt-chromium-on-polyethylene, and 44 (6%) oxidized zirconium-on-polyethylene. Differences in baseline demographic variables were accounted for using multiple logistic regression statistical analyses. Pearson's correlation coefficients were used to determine the association of noise generation with residual symptoms.
  
  
  RESULTS
  Overall, 9% (61 of 682; 95% confidence interval [CI], 7-11) of young patients undergoing primary THA reported noise generation. Females (12% [30 of 251 patients]) were noted to have an increased likelihood of reporting noise versus males (7% [30 of 431 patients]; odds ratio, 1.8; 95% CI, 1.1-3.1; p = 0.03). After controlling for potential confounding variables including female sex and length of followup, patients receiving a ceramic-on-ceramic or metal-on-metal bearing surface (14% [50 of 355]) reported an increased frequency of grinding, popping, and clicking in the 30 days before survey administration versus those receiving a polyethylene liner with a ceramic, oxidized zirconium, or cobalt-chromium femoral head (3% [10 of 327 patients]; odds ratio, 5.6; 95% CI, 2.7-11.5; p < 0.001). Noise generation was associated with increased pain (r = 0.23, p < 0.001) and stiffness (r = 0.22, p < 0.001) after THA.
  
  
  CONCLUSIONS
  When interviewed by an independent third party, patients receiving a metal-on-metal or ceramic-on-ceramic bearing reported a higher frequency of noise generation versus patients receiving a polyethylene liner after THA. Young patients undergoing THA should be counseled that noise generation could be associated with increased pain after THA.
  
  
  METHODS
  Level III, therapeutic study.
authors.affiliation: Department of Orthopaedic Surgery, Washington University School of Medicine/Barnes-Jewish Hospital, St Louis, MO, USA. namd@wudosis.wustl.edu.|Washington University Orthopedics, Barnes Jewish Hospital, 660 S Euclid Avenue, Campus Box 8233, St Louis, MO, 63110, USA. namd@wudosis.wustl.edu.
authors.forename: Denis
authors.initials: D
authors.lastname: Nam
authors.affiliation: Department of Orthopaedic Surgery, Washington University School of Medicine/Barnes-Jewish Hospital, St Louis, MO, USA.
authors.forename: Toby
authors.initials: T
authors.lastname: Barrack
authors.affiliation: Department of Orthopaedic Surgery, Washington University School of Medicine/Barnes-Jewish Hospital, St Louis, MO, USA.
authors.forename: Staci R
authors.initials: SR
authors.lastname: Johnson
authors.affiliation: Department of Orthopaedic Surgery, Washington University School of Medicine/Barnes-Jewish Hospital, St Louis, MO, USA.
authors.forename: Ryan M
authors.initials: RM
authors.lastname: Nunley
authors.affiliation: Department of Orthopaedic Surgery, Washington University School of Medicine/Barnes-Jewish Hospital, St Louis, MO, USA.
authors.forename: Robert L
authors.initials: RL
authors.lastname: Barrack
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects* / Q000295:instrumentation*; D001307:Auditory Perception; D001696:Biomechanical Phenomena; D016009:Chi-Square Distribution; D005260:Female; D006621:Hip Joint / Q000503:physiopathology / Q000601:surgery*; D006622:Hip Prosthesis; D006801:Humans; D016015:Logistic Models; D008297:Male; D061825:Metal-on-Metal Joint Prostheses; D008875:Middle Aged; D015999:Multivariate Analysis; D009622:Noise; D010147:Pain Measurement; D010149:Postoperative Pain / Q000175:diagnosis / Q000209:etiology; D011474:Prosthesis Design; D011475:Prosthesis Failure; D012189:Retrospective Studies; D012307:Risk Factors; D011795:Surveys and Questionnaires; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D055815:Young Adult