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Background: Early reports on modern ceramic-on-ceramic total hip replacements have demonstrated excellent clinical and radiographic results with few cases of catastrophic failure, which, in the case of earlier designs, often had been caused by implant fracture. Several reports, however, have noted the presence of audible squeaking. The purpose of the present study was to determine the incidence of squeaking in association with the use of this bearing couple.Methods: During the period from March 2003 to May 2005, three surgeons performed 159 total hip arthroplasties in 143 patients with use of a ceramic-on-ceramic bearing. One hundred and forty-nine hips (131 patients) were available for review after at least one year of follow-up. These patients were followed prospectively with use of the modified Hospital for Special Surgery hip score and a patient-administered questionnaire. Additionally, a control group of sixty hips (forty-eight patients) with a metal-on-polyethylene bearing was matched to the ceramic group on the basis of age, sex, and body mass index to compare the incidence of squeaking and other noises. Radiographic evaluations were performed according to previously established criteria.Results: Fourteen (10.7%) of 131 patients described an audible squeak during normal activities. However, squeaking was reproducible clinically in only four patients, and only one patient complained of squeaking before being presented with the questionnaire. The average Hospital for Special Surgery score improved from 19.8 preoperatively to 38.4 at the time of the latest follow-up, indicating excellent clinical results. Ninety-five percent of the patients had a satisfaction score of ≥8 of 10. Three hips dislocated. One of those three hips squeaked and was revised because of recurrent dislocations. One patient was considering revision because of squeaking. In the matched metal-on-polyethylene cohort, there were no cases of squeaking.Conclusions: The squeaking hip is a phenomenon that is unique to total hip replacements with hard-on-hard bearings. The incidence of squeaking in association with ceramic-on-ceramic bearings may be higher than previously reported as <1% of the patients in the present study reported this finding before being queried. The causes and implications of squeaking are yet to be determined. The use of hard-on-hard bearings offers many advantages in terms of wear reduction, especially for young and active patients. Nonetheless, patients considering ceramic-on-ceramic bearings should be counseled with regard to this phenomenon.Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.