The return to the use of big diameter femoral heads is now a well-established reality. The certainty of a better result is not only for young patients with an high functional demand, but also for elderly people, who need a reduction of enticement time and an increase of intrinsic Materials optimization and “hard to hard” bearings allowed surgeons to reduce the problem of volumetric wear and to guarantee some undeniable advantages such as: -better articular stability, thanks to the off-set restore -better range of motion -reduction of dislocation risk Increasing the femoral head diameter means increasing the off-set therefore the lever arm of the gluteus medius which is a great articular stabilizer. With the old metal to polyethylene and ceramic to polyethylene bearings, the bigger contact surface between the head and the cotyle interior certainly increased the volumetric wear in the past. The introduction of bearings at “low friction coefficient” ceramic-to-ceramic and metal-to-metal solved this problem and the undeniable improvement of the polyethylene preparation made this material to be considered safe even with big diameter heads. All articular stability parameters, in primis for the off-set, can be improved by the use of those solutions which are all efficient and able to give the surgeon the right mean to solve every single case. The eventuality to break ceramic heads is reported in literature and has fortunately reference to a low percentage, about 1.5% (“Biolox 28 mm ceramic-ceramic THR: 1.5% fractures 7 years f.u.” Toni, Alt.Bearings, NYC, 2002), but it maybe limits this kind of choice in cases of hip dysplasia, in which a bigger acetabulum uprightness increases the percentage of mistake in placing the cotyle. Nowadays, the diameter of the available heads is progressively increasing with the cotyle diameter (32, 36), so ceramic-ceramic is anyway an excellent solution for all other fatigued coxofemural articulations, above all if they are still eumorphic, and for female patients in which a worst bone quality reduces the choice of metal-metal. The metal-metal bearing finds instead a great indication in all patients, above all male patients with a good bone quality with high functional demand. The only reasons to go back preferring the metal-metal bearing are the reduction of the average age of the prosthesized patient and the increasing performance need. New techniques of superficial finish of the chrome-cobalt allowed surgeons to optimize the clearance, the self-smoothing ability in case of “streaks” of third body. Tests drawn in gate analysis demonstrated a reduced detachment between the two prosthesis components when the metal-metal operated patient makes the step, not only in favour of the bearing, but also of the choice of big diameters (“Metal on metal and distraction: an in vivo comparison.” Komistec et al; JBJS; October 2002). Moreover, other indications in literature show that there is no direct correlation between the cancer development and the metal-metal bearing prosthesis implant (Visuri, COOR 1996) (“The risk of cancer following total hip or knee arthroplasty” Tharani et al., JBJS May 2001), and even that there were no cobalt toxic serum levels able to justify cardio-pneumatie (Brodner, JBJS 1997). Independently by the materials choice, the bearing with big diameter heads undeniably reduces dislocation risk and accelerates the post-operative recovery even in old patients surgically treated for fracture. The larger distance a big diameter head has to cover in order to come out of the acetabular cavity (Jump distance) certainly reduces the number of dislocation cases. (“Large versus small femoral heads in metal on metal total hip arthroplasty” – All those reasons pushed us to believe in “hard to hard” bearings with big diameter, whose results could not be more satisfying. Nevertheless, there are some complications which can make us think, such as cases of pseudocancer for metal-metal bearing and the squeaking in the ceramic-ceramic bearing. The introduction of last generation polyethylene could bring the golden standard near the ceramicpolyethylene again.
