FEMORAL NECK MODULARITY: A BRIDGE TOO FAR – OPPOSES

Distal neck modularity places a modular connection at a mechanically critical location. However, this is also the location that confers perhaps the greatest clinical utility. Assessment of femoral anteversion in 342 of our THR patients by CT showed a range from −24 to 61 degrees. The use of monoblock stems in some of these deformed femurs therefore must result in a failure to appropriately reconstruct the hip and have increased risks of impingement, instability, accelerated bearing wear or fracture, and adverse local tissue reaction (ATLR). However, the risks of failing to properly reconstruct the hip without neck modularity must be weighed against the additional risks introduced by neck modularity. There are several critical design, material, and technique variables that are directly associated with higher or lower incidences of problems associated with modular neck femoral components. These include modular neck length, design and material of both parts including the junction design, wall thickness of the receiving junction, assembly force, and bearing diameter and material. With regard to stem design and material, it has been clearly shown that the incidence of titanium neck fractures is higher in stems with a thinner wall-thickness of the receiving junction than in stems with a thicker wall-thickness. Moreover, titanium necks have been largely replaced with CoCr necks with significantly higher yield and fatigue strength. It remains to be seen if the introduction of CoCr necks will decrease or increase the risks associated with distal neck modularity. With respect to titanium necks, our experience has shown no adverse local tissue reaction, no fractures of short necks (0 of 370) and a 0.34% incidence of fractures in long necks (2/580) at 3 to 8 years following surgery. This lower incidence of neck fracture compared to other reports may relate to the relatively more rigid stem and thicker wall of the junction receiving the neck compared to other stems. With respect to CoCr modular necks, one device that mated the CoCr modular neck with a beta-titanium alloy femoral component has been shown to have a high incidence of ALTR and has been recalled. While the CoCr on Conventional Titanium Alloy modular neck experience has had a statistically significantly lower incidence of problems, we believe that we have identified two cases of ALTR. If that is the case, the CoCr neck experience may well have a higher incidence of problems that the Ti neck experience. In summary, placing a modular connection at the stem-neck junction has great clinical utility but this is a very design sensitive location. There are risks associated with the use of non-modular neck components that are incapable of properly reconstructing the spectrum of pathology that presents. This failure can lead to instability, impingement, and polyethylene fracture. Yet, the use of titanium modular necks has a small risk of component fracture while the use of cobalt-chrome modular necks may have a higher risk of adverse local tissue reaction. While the existence of a modular neck may offer great advantages at the time of primary reconstruction and of future revision, currently the risk/benefit for the use of these components is strongest in patients with more significant anatomical abnormalities or more complex revision settings.