Key Points:. Historically, 22.25, 26, 28, or 32 mm metal femoral heads were used in primary total hip arthroplasty, but innovations in materials now permit head sizes 36 mm or larger. Stability and wear of primary total hip arthroplasty are related to the diameter and material of the femoral head. Larger diameter femoral heads are associated with increased joint stability through increases in arc range of motion and excursion distance prior to dislocation. Fixation of the acetabular component may be related to the size of the femoral head, with increased frictional torque associated with large diameter heads and certain polyethylene. Linear wear of highly crosslinked polyethylenes seems unrelated to femoral head diameter, but larger heads have been reported to have higher volumetric wear. Mechanically assisted crevice corrosion at the connection between the modular femoral head and neck may be associated with the femoral head size and material. Cobalt chromium alloy, alumina ceramic composite, or oxidised zirconium femoral heads on highly crosslinked polyethylene are the most commonly used bearing surfaces, but each may have unique risks and benefits. Conclusions. At present, there is a wave of enthusiasm for the routine use of “large” (32, 36 mm, or larger) femoral heads with highly crosslinked polyethylene for the vast majority of patients having a primary THA. It may be reasonable to consider the “graduated femoral head-outer acetabular diameter system”, using 28 mm femoral heads with “smaller” acetabular components (<50 mm), 32 mm femoral heads with acetabular components 50 – 56 mm outer diameter, and 36 mm or larger femoral heads with acetabular components 58 mm or larger in diameter, to minimise both the risk of dislocation and the frictional torque. Although the linear wear of highly crosslinked polyethylene appears to be independent of head size, the reported increase in volumetric wear with large femoral heads and highly crosslinked polyethylene requires further study, and should temper the use of femoral heads 36 mm or larger in younger and more active patients. With its long and successful history, it is difficult to recommend the complete abandonment of the cobalt chromium alloy femoral head in all patients having a primary THA. Alumina ceramic or oxidised zirconium heads may be considered for younger, heavier, and more active patients, who seem to have the highest risk of trunnion corrosion. Surgeons and patients should be aware of the unique possible complications of these two newer femoral head materials

Uncemented metal-on-polyethylene total hip arthroplasties (THAs) have had a modular cobalt-chrome alloy head since their introduction in the early 1980's. Retrieval analysis studies and case reports in the early 1990's first reported corrosion between the femoral stem trunnion (usually titanium alloy) and cobalt-chrome alloy femoral head. However, then this condition seemed to disappear for about two decades? There are now numerous recent case series of this problem after metal-on-polyethylene THA, with a single taper or dual taper modular femoral component. Metal ion elevation, corrosion debris, and effusion are caused by mechanically assisted crevice corrosion (MACC). These patients present with diffuse hip pain, simulating trochanteric bursitis, iliopsoas tendinitis, or even deep infection. Trunnion corrosion, with adverse local tissue reaction, is a diagnosis of exclusion, after infection, loosening, or fracture. The initial lab tests recommended are: ESR, CRP, and serum cobalt and chromium ions. With a metal-on-polyethylene THA, a cobalt level > 1ppb is abnormal. Plain radiographs are usually negative, but may show calcar osteolysis or acetabular erosion or cyst. MARS MRI may be the best imaging study to confirm the diagnosis. Hip aspiration for culture and cell-count may be necessary. The operative treatment is empiric, with debridement, and head exchange with a ceramic head-titanium sleeve (or oxidised zirconium head) placed on the cleaned trunnion. The femoral component may have to be removed if there is “whole trunnion failure”. This usually relieves the symptoms, but the complication rate of this procedure may be high

The advent of highly cross-linked polyethylene has resulted in improved wear rates and reduced osteolysis with at least intermediate follow-up when compared to conventional polyethylene. However, the role of alternative femoral head bearing materials in decreasing wear is less clear. The purpose of this study was to determine in-vivo polyethylene wear rates across ceramic, Oxinium, and cobalt chrome femoral head articulations. A review of our institutional database was performed to identify patients who underwent a total hip arthroplasty using either ceramic or oxidised zirconium (Oxinium) femoral head components on highly cross-linked polyethylene between 2008 and 2011. These patients were then matched on implant type, age, sex and BMI with patients who had a cobalt chrome bearing implant during the same time period. RSA analysis was performed using the centre index method to measure femoral head penetration (polyethylene wear). Secondary quality of life outcomes were collected using WOMAC and HHS Scores. Paired analyses were performed to detect differences in wear rate (mm/year) between the cobalt chrome cohorts and their matched ceramic and Oxinium cohorts. Additional independent group comparisons were performed by analysis of variance with the control groups collapsed to determine wear rate differences between all three cohorts. A total of 68 patients underwent RSA analysis. Fifteen patients with a ceramic femoral head component and 14 patients with an Oxinium femoral head component along with the same number of matched patients with cobalt chrome femoral head component were included in the analysis. The time in vivo for the Oxinium (5.17 +/− 0.96 years), Oxinium matched cohort (5.13 +/− 0.72 years), ceramic (5.15 +/− 0.76 years) and ceramic matched cohort (5.36 +/− 0.63 years) were comparable. The demographics of all bearing surface cohorts were similar. The paired comparison between the Oxinium and cobalt chrome cohorts (0.33 vs. 0.29 mm/year, p=0.284) and ceramic vs cobalt chrome cohorts (0.26 vs. 0.20 mm/year, p=0.137) did not demonstrate a significant difference in wear rate. The independent groups analysis revealed a significantly higher wear rate of Oxinium (0.33 mm/year) compared to cobalt chrome (0.24 mm/year) (p = 0. 038). There were no differences in HHS and WOMAC scores between the Oxinium and cobalt chrome cohorts (HHS: p = 0.71, WOMAC: p=0.08) or the ceramic and cobalt chrome cohorts (HHS: p=0.15, WOMAC: p=023). This study presents evidence of a greater wear rate (mm/year) of the Oxinium femoral head component compared to a cobalt chrome femoral head component. This difference was not demonstrated in the ceramic femoral head component. Despite this difference, there were no clinical differences as measured by the HHS and WOMAC. Future research should focus on factors that may contribute to the higher wear rate seen in the Oxinium cohort