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• W2436368053 abstract "I read with interest the article by Tanzer et al., “Primary cementless total hip arthroplasty using a modular femoral component” (J Arthroplasty 16 (Suppl 1): 64, 2001). I commend the authors for diligence at following up their series. However, I must take issue with the conclusions reached in the final paragraph of the Discussion section: In primary THA, apart from cases of developmental dysplasia of the hip that often require correction of abnormal femoral anteversion or atypical placement of the metaphyseal sleeve, modularity is of no particular benefit. The attributes of the S-ROM design with regard to initial stability can be obtained equally with a nonmodular stem that retains the metaphyseal shape and the distal splines. Despite the overall excellent clinical results reported in this study, it seems prudent to minimize the use of modularity, while maximizing the use of implant design features and instrumentation that contribute to initial and long-term stability. These conclusions do not follow from the data presented and represent the opinion of the authors only. They should not be presented as recommendations based upon the results of this study. The data presented, as I read the manuscript, offer compelling evidence of a stem that is functioning exceedingly well at mid-term follow-up evaluation. Bony ingrowth was achieved radiographically in 100% of the cases; there were no cases of revision for aseptic loosening. The pattern of osteolysis reported indicates that in all but a single case the design of the prosthesis seems to limit the effective joint space to proximal to the stem-sleeve junction and effectively seals the more distal areas of the femur. The concerning radiographic features on which the authors choose to focus are the changes consistent with proximal stress shielding and osteloysis. The stress shielding changes, as pointed out by the authors, must certainly be seen as a byproduct of the successful ingrowth of the prosthesis. To the extent that this compromises the integrity of the proximal femur or long-term fixation of the component, it is certainly a problem worth addressing with long-term follow-up and possible design modifications. The osteolysis is of greater immediate concern, with an incidence of 42% reported in this manuscript. However, the authors seem to unfairly and inappropriately implicate modularity as the cause of osteolysis in the final paragraphs of their discussion. In truth, the causes of osteolysis are multifactorial, and the authors’ own data show that 80% of osteolysis occurs in the presence of eccentric polyethylene wear of the acetabular liner. There are only 5 (<10%) cases that escape radiographic explanation for the osteolysis. The most important point to be made is that no data presented suggest that modularity is the cause of this osteolysis. Although conjecture might implicate the modularity of the stem and sleeve as a generator of debris, one could just as easily conjecture that head size, acetabular design, polyethylene quality or surgeon technique contributed to the osteolysis, which as yet lacks etiology. To condemn modularity, which has offered immense versatility to the surgeon performing total hip arthroplasty (THA), without any evidence-based foundation is inappropriate, and scientifically unsound. Furthermore, to implicate the S-ROM prosthesis design as the cause of this problem, when there is extensive laboratory and clinical data available to suggest that its modularity has not proven problematic in this regard is to ignore quality scientific data in favor of opinion alone. The editorial process should guard against this kind of random hypothesizing that neither follows from the data of the manuscript nor finds foundation in the scientific literature. Even the references cited to support the claims against modularity do not substantiate the argument against the S-ROM prosthesis. In fact, the stem-sleeve junction is addressed in only one of the articles, in which the modular junctions were mechanically tested. One of the conclusions of the authors in that study (3 of whom overlap with the authors of the current study) was that, “It is unknown what quantity of particulate material is sufficient to cause macrophage-mediated osteolysis or whether the debris from modular junctions can cause third-body wear of the articulating surfaces, [1Bobyn J. Tanzer M. Krygier J. Concerns with modularity in total hip arthroplasty.Clin Orthop. 1994; 298: 27PubMed Google Scholar]” The other articles discuss problems with either head-neck junctions or with acetabular liner-shell junctions, the use of both of which the current authors seem to embrace along with the majority of arthroplasty surgeons in the world [2Barrack R. Burke D. Cook S. Complications related to modularity of total hip components.J Bone Joint Surg Br. 1993; 75: 688PubMed Google Scholar, 3Collier J. Surprenant V. Jensen R. Corrosion between the components of modular femoral hip prostheses.J Bone Joint Surg Br. 1992; 74: 511PubMed Google Scholar]. I firmly believe, based on excellent clinical reports of the S-ROM [4Christie M. Deboer D. Trick I. Primary total hip arthroplasty with use of the modular S-ROM prosthesis.J Bone Joint Surg Am. 1999; 81: 1707PubMed Google Scholar] and data suggesting a paucity of particulate debris from the stem-sleeve junction [5Bobyn J. Dujovne A. Krygier J. Young D. Surface analysis of the taper junctions of retrieved and in vitro tested modular hip prostheses.Biological, material and mechanical considerations of joint replacement. Raven Press, New York1993Google Scholar], that the S-ROM is not the major source of the osteolysis seen in this series. It would be of great scientific interest to review the remainder of the authors’ series of THA during the same interval using different stems and to evaluate the incidence and appearance of osteolysis in those hips. It may in fact vindicate the S-ROM as a contributor to the osteolysis problem in this study and implicate other components or identify other sources of osteolysis-generating debris. In summary, although the data in this article are excellent, the recommendations in the final paragraph of the discussion do not follow from that data. Neither the S-ROM nor modularity can be indicted by this study. Simply because the subject of the study is the S-ROM, the authors should not condemn this immensely versatile and proven valuable modularity without a sound scientific basis. I believe that the authors should have concluded with the comment found earlier in their discussion, “it cannot be determined whether the femoral osteolytic cysts were influenced by fretting debris from the S-ROM stem-sleeve modular junction.”" @default.
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