The Journal of Arthroplasty Vol. 27 No.

7 2012

Femoral Stem Fracture and In Vivo Corrosion of

Retrieved Modular Femoral Hips
J. Caitlin Huot Carlson, MS, Douglas W. Van Citters, PhD, John H. Currier, MS,
Amber M. Bryant, BE, Michael B. Mayor, MD, and John P. Collier, DE

Abstract: A series of 78 retrieved modular hip devices were assessed for fretting and corrosion.
Damage was common at both the head-neck junction (54% showing corrosion; 88% showing
fretting) and at the stem-sleeve junction (88% corrosion; 65% fretting). Corrosion correlated to in
vivo duration, patient activity, and metal (vs ceramic) femoral heads but did not correlate to head
carbon content. Femoral stem fatigue fracture was observed in seven retrievals; all had severe
corrosion, were under increased stress, and were in vivo longer than the non-fractured cohort.
This study emphasizes the potential for stem fracture when small diameter femoral stems with
large offsets are used in heavy and active patients. Designs which reduce fretting and corrosion in
modular implants is warranted as patients demand longer lasting implants. Keywords: stem,
fretting, corrosion, modularity, fracture.
© 2012 Elsevier Inc. All rights reserved.

Modularity in total hip arthroplasty devices has notable
advantages, allowing surgeons to optimize implant fit and
stability in primary procedures as well as more complex
revision cases. Femoral head-neck modularity allows
intraoperative adjustment of femoral head offset and
neck length, while modular multipiece stems help ensure
the most appropriate match for varying proximal and
distal femoral geometries [1]. Although these modular
connections are commonplace, they are a potential locus
of fretting and of corrosion resulting from both the crevice
environment and motion at the interface [2-14].
The current study investigated 78 retrieved modular
hip implants of a single design (S-ROM; DePuy Ortho-
paedics, Warsaw, Ind). The objective was to identify
patient and device factors which could be contributing to
the extent and severity of corrosion in a cementless
titanium alloy hip. A specific hypothesis investigated
was whether the carbon concentration of the Co-Cr-Mo
alloy metal head influenced corrosion behavior. Seven
cases of femoral stem fracture in this series were studied
to determine cause of failure. The study was motivated
by the array of potential clinical effects of corrosion in
From the Thayer School of Engineering, Dartmouth College, Hanover, New
Hampshire.
Supplementary material available at www.arthroplastyjournal.org.
Submitted March 15, 2011; accepted November 21, 2011.
The Conflict of Interest statement associated with this article can be
found at doi:10.1016/j.arth.2011.11.007.
Reprint requests: John H. Currier, MS, Thayer School of Engineering,
Dartmouth College, 8000 Cummings Hall, Hanover, NH 03755.
© 2012 Elsevier Inc. All rights reserved.
0883-5403/2707-0022$36.00/0
doi:10.1016/j.arth.2011.11.007
modular prosthetic joints and by the small number of
retrieval studies that document corrosion of modular-
body hip implants in a large series of single design com-
ponents [12,14]. Investigation of the S-ROM design
allowed for examination of two different modular
junctions: head-neck (dissimilar alloys) and stem-sleeve
(similar alloys), which has also been seldom reported [15].
Materials and Methods
Retrieval Evaluation
Seventy-eight S-ROM femoral stems (DePuy Ortho-
paedics), 50 mating femoral sleeves, and 72 femoral
heads, with accompanying patient information, were
received into an institutional review board–approved
retrieval program. Average in vivo duration was 50.8
months (0-185 months) in 48 males and 30 females. The
average age at the time of retrieval was 63.2 years (34-88
years); 60% of devices were primary hips and 40%
were revisions. Table 1; available online at www.
arthroplastyjournal.org, indicates the reason for retrieval
and other patient characteristics. Seven of the devices
were removed due to femoral stem fracture occurring
proximally in the stem-sleeve tapered region; average in
vivo duration of the fractured devices was 110.9 months
(range, 45.5-182.9).
The femoral heads were metal (44), ceramic (19), and
ceramic with a metal sleeve (11). Femoral stems were
forged Ti-6Al-4V alloy. Femoral sleeves were porous
coated and forged Ti-6Al-4V alloy, and femoral heads
were either a low carbon (b0.06%) or high carbon
(N0.2%) Co-28Cr-6Mo alloy.

1389
1390 The Journal of Arthroplasty Vol. 27 No. 7 August 2012
Retrieved devices were soaked in formalin for 48
hours, dried for 48 hours and cleaned of dried organic
material or other debris prior to evaluation under a
binocular dissecting microscope (Nikon, Tokyo, Japan)
at 10×. Each retrieved component was assessed for
severity of fretting and of corrosion at the modular
interfaces (head-neck junction and stem-sleeve taper)
using a modified retrieval analysis rating method deve-
loped originally by Hood et al [16]. Devices were rated
on a scale of 0 to 3: 0 indicating no evidence of damage
and 3 indicating severe damage. An estimate of the
percentage of corroded area (qualitative assessment) on
both the stem and sleeve was also documented by a
single observer [5,12]. The adherence to a single ob-
server was based on the desire to have the qualita-
tive assessment provided by the same clinician
researcher who has assessed thousands of components
in the institution's retrieval program. Corrosion was
defined as alteration of a surface with no directionality.
Fretting was defined as alteration of surface detail in
the sleeve/stem interface with visible directionality,
acknowledging that small or subtle directional markings
may be superseded by subsequent corrosion.
Visual assessment was complemented by detailed
quantification of the corroded area on the femoral
stems using a Keyence Digital Microscope VHX-1000
(Keyence Corporation, Osaka, Japan). To facilitate this
analysis the stem surface was divided into four regions
(medial, lateral, anterior, and posterior). A tapered
fixture was developed to hold the hip stems and expose
a 60 degree circumferential segment. The total surface
area and corroded surface area within each segment
was measured using image analysis software on the
digital microscope system (Fig. 1). The corroded surface
area was normalized to the total surface area. The
photogrammetric error associated with measuring the
surface area of a femoral stem was determined to be
+6% to −8% based on the distance of the microscope
lens from the object, femoral stem geometry, and
masking fixture.
Fretting severity ratings, corrosion severity ratings, and
estimated corrosion area were performed by one indi-
Fig. 1. (A) Region to be measured, (B) total surface area of a given segment, and (C) corrosion areas on that segment with
individual area measurements labeled in yellow.
vidual. To avoid any bias, corrosion area was quantified
by a different individual using the digital microscope.
Pits and areas of noticeable material removal or accrual
were further characterized for depth and size using
white light interferometery (depth resolution: 0.01 μm,
camera resolution: 0.4-1.2 μm; NewView 7300, Zygo,
Middlefield, Conn).
A selection of fractured and non-fractured femoral
stems were sectioned, mounted, polished and etched
with aqua regia for metallurgical examination. Cross-
sections were examined under a Scanning Electron
Microscope (JEOL5310LV, Japan) at 15 kV (spot size of
10); images were taken at 500× magnification.
Femoral Stem Stress
Bending stress in femoral stems was calculated using a
simplified analysis based on the Bernoulli-Euler Beam
theory. The parameters used in the calculation were the
applied load (F), the offset distance (D), and the stem
radius (R) (Fig. 2).
Maximum tensile stress occurring on the lateral aspect
of the stem is given by the equation below, where (M) is
the moment, (y) is the distance from the neutral axis, (I)
is the area moment of inertia, (F) is the force, and (A) is
the section area:
 
My F 4FD F
r= − = −
I A pR3 pR2
Due to the lack of patient weight data for a number
of retrievals (required to determine F), an index of
relative stem stress was computed using D/R 3. This stress
equation assumes a constant cylindrical cross-section or
radius (R). Because the S-ROM stem is tapered at
approximately 3°, the mid-distal stem radius was used
for calculations. The total offset distance (D) was cal-
culated using stem offset, neck length, and femoral head
offset. The resulting stress metric can be considered an
index of a design's sensitivity to patient weight.
Femoral Head Carbon Concentration
Metal femoral heads were electrolytically etched to
distinguish low- and high-carbon metallurgy. A graphite
 Stem Fracture and Corrosion in Modular Hips  Huot Carlson et al
Fig. 2. Schematic of a femoral stem and the variables used in
the stress analysis.
rod and a small portion (approximately 1 cm 2) of each
femoral head were submerged in a 10% HCl solution,
and a voltage of approximately 7V was applied for 10
seconds. A hazy appearance, evidence of successful
etching of the metal's microstructure, was indicative
high carbon content, given the low exposure times [17].
Classification of metallurgy was possible for 40 of the 44
metal heads in this series; 28 were of low carbon con-
tent (approximately 0.05% carbon), and 12 had a high
carbon content (approximately 0.25% carbon). All
femoral heads in the study were produced by forging.
Statistical Methods
Bivariate correlations were used to evaluate relation-
ships among variables. The Spearman Rho Correlation
Coefficient (SRCC), and associated P value for all
reported correlations were evaluated using SPSS Soft-
ware version 18 (SPSS Inc, Chicago, Ill). Additionally, a
one factor analysis of variance was performed to
evaluate differences in means between groups; results
were considered statistically significant at P b .05 for
all procedures.
Results
Nearly 90% of the components showed some evidence
of in vivo damage (1-3 rating) at modular interfaces
(Fig. 3). At the head-neck junction, fretting was identified
on 74% of heads and 88% of necks. Fretting was less
common at the stem-sleeve interface with fretting seen
on 65% of stems and 42% of sleeves. Corrosion was
more prominent at the stem-sleeve interface; 88% of
stems and 86% of sleeves had corrosion compared to 54%
of heads and 36% of neck tapers.
1391
Fig. 3. Femoral stems (A) and sleeves (B) of increasing
corrosion severity rating; 1 to 3 from left to right.
Metal heads were significantly more prone to corro-
sion of the head bore (54%) than were the titanium-
sleeved ceramic heads (18%) (P = .026). Metal heads
were associated with significantly more corrosion of the
stem neck: average visually assessed severity rating of
0.95 compared to 0.16 (ceramic) and 0.18 (sleeved
ceramic); (P b .0001). Head type did not correlate to
stem/sleeve corrosion (analysis of variance P = .65) or to
stem/sleeve fretting (P = .20).
Quantitative results showed that corrosion was most
dominant on the medial aspect of the femoral stem
compared to the other three regions (P b .003). Corrosion
was more prominent laterally than anteriorly (P = .02)
and posteriorly (P = .14), although not significantly in the
latter comparison. The propensity for corrosion was no
different between the anterior and posterior aspects (P =
.35) (Table 2).
In vivo duration was significantly correlated to corro-
sion severity (0-3 rating scale) on the stem (P b .0001,
SRCC=0.523) and on the sleeve (P b .0001, SRCC =
0.550) as well as with the qualitative assessment of
corrosion area on the stem (P b .0001, SRCC = 0.499)
and sleeve (P = .002, SRCC = 0.467). Similarly, duration
was significantly related to area of corrosion on the
stem (P b .0001, SRCC = 0.628). In vivo duration did
not significantly correlate to corrosion in the head bore
(P = .19, SRCC = 0.189) or on the neck taper (P = .93,
SRCC= −0.010).
1392 The Journal of Arthroplasty Vol. 27 No. 7 August 2012

Table 2. Relative Amount of Corrosion (Percent of Total

Corrosion) in a Given Location on the Femoral Stem (n=74)
Location on Percentage of Overall Corrosion in
Femoral Stem a Given Location
Medial 32.5%
Anterior 20.3%
Lateral 25.0%
Posterior 22.2%

Mating surfaces at both modular junctions showed

matching patterns of corrosion and fretting. Corrosion
severity of the head bore was significantly correlated to
that of the neck taper (P b .0001, SRCC = 0.840) and
similarly between the stem body and the sleeve (P b
.0001, SRCC = 0.886). Fretting severity on the femoral
head was correlated to that on the neck taper (P b .0001,
SRCC = 0.640); and fretting on the stem body correlated
to that on the sleeve (P b .0001, SRCC = 0.537).
When examining the correlation of corrosion on the
two modular junctions with one another, the severity
of corrosion damage at the head-neck interface was
significantly correlated to that at the stem-sleeve
interface (P = .001, SRCC = 0.541). Fretting damage
did not correlate in a similar fashion (P = .26,
SRCC=0.156).
The geometrical parameters stem diameter, stem
length, stem offset, neck length, and femoral head size
demonstrated no correlation to the extent or severity of
corrosion or fretting at either modular location nor did
the patient characteristics patient age, weight, height,
gender, left or right hip, primary or revision. However
the surgeon-determined patient activity level prior to
the onset of symptoms showed a statistically significant
relationship to the corrosion severity at the head-neck
(P = .013, SPCC=0.533) and at the stem-sleeve junction
(P = .004, SPCC = 0.649). The average (D/R 3) ratio
(metric for femoral stem stress) was 2.33 × 10 −2 mm −2
(range, 9 × 10 −3 mm −2 to 6.1 × 10 -2 mm -2) for the 72
devices for which the information was provided.
The carbon content of the metal heads did not corre-
late to corrosion at the head/neck taper (SPCC = −0.048,
P = .8) and did not correlate to corrosion at the
stem/sleeve interface (SPCC = 0.039, P = .8).
The fracture surfaces of all 7 cases of fractured stems
showed fatigue striations that initiated laterally and
progressed medially. All stems and sleeves had severe
corrosion rated at a 3, covering between 65 and 100% of
the surface area (Fig. 4).
Certain device and patient characteristics were found
to be statistically different among the fractured stem
population (Table 3). Fractured stems were smaller
diameter than non-fractured stems (P = .043), with
generally larger offset distances, and thus had larger
calculated stress metric for the stem (P = .009). Fractured
devices were in vivo for longer duration, showed more
severe and more extensive corrosion at both modular
Fig. 4. Images (A) and (C) illustrate the fracture surface of two
different implants; the direction of crack propagation is
indicated by the white arrow. Circumferential corrosion
occurring in the stem-sleeve taper, near the fracture location;
(B) and (D).
interfaces, and exhibited significantly less fretting at
those interfaces than non-fractured devices. There was
no statistical difference in patient weight, height, age, or
surgeon-determined activity level between the non-
fractured and fractured populations. Images of the
femoral stem microstructure for a non-fractured and
fractured femoral stem show similar alpha/beta micro-
structures, typical for this alloy (Fig. 5).
3D surface profiles of localized corrosion areas on
femoral stems commonly showed areas of pitting
and/or step-wise changes in depth (Fig. 6). Depth of
pits was as great as 350 μm in the severely corroded
devices. Regions of corrosion can extend over several
square centimeters.
Discussion
Corrosion at the femoral head-neck junction in
retrieved devices has been extensively documented in
retrievals [3-6,10,15,18]. A study by Collier and col-
leagues demonstrated that over half of retrieved mixed-
alloy modular junctions showed duration-dependent
evidence of crevice corrosion, while 100% of similar-
alloy components showed none [5]. It was hypothesized
that galvanic effects and disruption of the passive layer
influenced the rate of crevice corrosion. Similarly, Gilbert
and colleagues documented corrosive attack in mixed
(Ti-6Al-4V/Co-Cr) and similar metal (Co-Cr/Co-Cr)
combinations. Of 148 retrievals, 23% to 35% of heads
 Stem Fracture and Corrosion in Modular Hips  Huot Carlson et al 1393

Table 3. Device or Patient Variables Which Showed Statistical Differences When Considering the Non-Fractured Population
(n=71) Compared To The Fractured Population (n=7)
Non-Fractured Population (n=71) Fractured Population (N=7)
Variable Average Values Average Values P
Femoral stem diameter (mm) 13.0 11.6 .043
Femoral stem stress normalized to force (σ/F) (mm−2) 2.22 × 10-2 3.28 × 10-2 .009
Duration (months) 45.5 110.9 .001
Corrosion severity: head bore (0-3 scale) 0.86 2.00 .014
Corrosion severity: stem neck (0-3 scale) 0.54 1.29 .026
Fretting severity: head-neck (0-6 scale) 2.35 0.5 .001
Corrosion severity: stem (0-3 scale) 1.51 3.00 b.0001
Corrosion severity: sleeve (0-3 scale) 1.49 3.00 b.0001
Fretting severity: stem-sleeve (0-6 scale) 4.65 0.00 .001
Qualitative corrosion estimate: stem (%) 11.6 100.0 b.0001
Qualitative corrosion estimate: sleeve (%) 13.6 97.5 b.0001
Quantitative corrosion assessment: stem (%) 9.5 100.0 b.0001
Patient weight (lb) 185 208 .364
Patient height (in) 68 68 .778
Patient age (y) 63 66 .626
Patient activity level (0-4 scale) 2.9 3.5 .136

and 14% to 16% of necks showed damage due to cor-
rosion [6]. Mathiesen et al. expanded on these reports by
documenting the clinical effects associated with “macro-
scopic” corrosion at head-neck tapers. Their series
reported two neck fractures and extensive tissue necrosis
due to metal particles in the surrounding tissue [10].
These early reports of fretting, corrosion and wear
among mixed and similar alloy components established
that the process was not solely galvanic as a result of
Co-Cr and Ti-6V-4Al alloy coupling. The most widely
accepted explanation for corrosive damage was pro-
posed by Gilbert and Jacobs [19], termed mechanically
assisted crevice corrosion. This process is initiated by
mechanical motion (fretting) at the modular interface,
which disrupts the oxide or passive film. Exposure of the
base metal to joint fluid results in repassivation and an
increased rate of ionic dissolution, further altering the
surrounding environment and eventually leading to
localized corrosion [19].
An important contribution of the current study was
that it examined two regions of modularity: the head-
neck junction, and the stem-sleeve interface, for
which reports regarding corrosion have been limited
[12,14,20]. It also permitted the determination of
possible correlations between the corrosion sites. The
current study found that fretting, a hypothesized pre-
cursor to corrosion, occurred more often and was
more readily visible at the head-neck interface. On
the stem-sleeve, taper corrosion was more prevalent
and more severe than fretting. The mixed alloy

Fig. 5. SEM images of the microstructure of a fractured femoral stem (right) and a non-fractured stem (left). Microstructures
appear to be the same.
1394 The Journal of Arthroplasty Vol. 27 No. 7 August 2012
Fig. 6. (A) Digital microscope image of a pitted and corroded region of a femoral stem. On right, screen images of light
interferometer output and analysis. (B) Areal profile data in color spectrum and (C) linear profile along the trace indicated in (B);
maximum height differential is 325 μm.
couple at the head-neck taper (Co-28Cr-6Mo on Ti-
6Al-4V) versus the similar alloy couple (Ti-6Al-4V on
Ti-6Al-4V) at the stem-sleeve taper cannot be ignored
as a differentiating factor. However, it has been
documented that both mixed and similar alloy pairs
are susceptible to corrosion [6,18]. Equally important
to the tribology within the different tapers are the
passive (oxide) film properties and surface-roughness
of the components. These aspects of the modular
interaction were not studied in this investigation but
may play a role in the different frequencies of fretting
and corrosion.
In vivo duration was a significant predictor of stem-
sleeve corrosion but not of corrosion at the head-neck
interface. The environment in which the stem engages
the sleeve (already implanted in the metaphysis) is
done in the presence of blood, organic fluids, and tissue
[20]. This increases the probability for corrosion at that
interface, as fluid within the taper, acting as the conduit
for ion exchange, may be present during the first cycles
of use [12,21]. Others have demonstrated that the
presence of fluid in a tapered junction prevents the two
surfaces from achieving a friction fit, affecting the
likelihood of fretting-corrosion under in vivo loads [22].
The assembly environment for the head-neck taper
may be more likely to occur under dry conditions,
which might delay or eliminate fretting at that
interface. Gilbert et al showed that although a dry
assembly of a head to the stem-neck cannot completely
prevent fretting, it increases the load required to initiate
fretting corrosion [23].
Comparison of stem damage in components with
varying femoral head types showed that the metal
heads resulted in more severe corrosion on the stem's
head-neck taper than ceramic heads. This is consistent
with the work of Hallab and colleagues who examined
the effect of head type on fretting-corrosion of the
head-neck taper and found greater metal release and
potentiodynamic fretting in metal-metal couples than
in ceramic-metal couples [24]. They postulate that
either (a) the amount of micromotion is significantly
reduced in a ceramic-metal couple as a result of greater
mechanical interlocking or (b) both modular connec-
tion types incur the same amount of micromotion, but
the metal-metal connection produces significantly
more metal ions, leading to corrosion [24]. The current
results would support postulate (b) as fretting severity
ratings were no different among the three head types,
either within the head bore, or on the neck taper.
Categorization of metal femoral heads into low- and
high- carbon concentration showed no statistical differ-
ence in corrosion behavior at either interface. This
result does not support the hypothesis that the higher
carbon concentration femoral heads might be less corro-
sion resistant.
The present study quantified corrosion area on
femoral stems using digital image analysis as a compar-
ison to a more qualitative, visual determination of
corrosion extent and severity. Numerous other studies
have qualitatively identified in vivo damage in retrieved
hip implants [2,3,5,12,14,15,20]; however, quantifica-
tion has been much less common [7]. A notable
 Stem Fracture and Corrosion in Modular Hips  Huot Carlson et al
exception is the in vitro study by Bobyn et al., in which
modular hips (including the S-ROM) were fatigue-tested
in solution, and the amount of particulate metal debris
was measured to quantify fretting [7].
An advantage of the quantitative light microscope
imaging technique developed in the present study is its
ability to isolate regions for which corrosion is more
prevalent. Corrosion was found to be greatest on the
medial aspect of femoral stems; directly opposite the
location of maximum tensile stress when the device is
loaded in vivo. Although further studies are necessary
to definitively explain the prominent medial corrosion,
our findings are similar to a previous study where
corrosion was also found to be mainly proximal and
medial in S-ROM stem-sleeve interfaces [12].
In the current study, devices in more active patients
were more severely corroded at both of the modular
junctions. Presumably, increased cyclic loading and
fretting of the interface creates an environment condu-
cive to corrosion: one that might occur to a lesser degree
in low activity patients. This finding echoes previously
voiced concerns over the long-term performance of
modular implants in active patients [21,25].
The seven fractured devices all demonstrated severe
(rating of 3 in all cases) corrosion at the stem-sleeve
interface and the areal extent approached 100%, How-
ever, the actual failures were due to fatigue crack
propagation. Fatigue striations in all cases had loci of
initiation on the lateral aspect of the stem and progress
medially. Micrographs of the fractured and non-frac-
tured components do not establish the presence of any
metallurgical flaws; rather they are typical of a forged
Ti-6Al-4V alloy in both cases. The fine grain size is con-
sistent with the manufacturing process [17].
Corrosion on the circumference of the stems was notable
in fractured devices. Features consisted of pits (individual
as well as clusters), shelved areas, as well as areas of
material accrual. Depth profiles from white
light interferometery demonstrate corroded regions with
depths ranging up to 350 μm. Corrosion pits of this mag-
nitude have been previously identified in corroded and
hydrogen embrittled modular titanium implants [2,5].
It was determined that there were several factors
which separated the fractured group from the non-
fractured group, the most important of which was the
significant difference in the femoral stem stress between
the groups. The seven fractured devices had larger D/R 3
ratios, indicating that, for a given patient weight, these
devices were under more stress, thereby reducing the
number of cycles prior to crack initiation [25]. Careful
consideration should be given to the combined effect of
patient weight, total offset, and stem diameter to help
reduce the instance of femoral stem failure.
Although stem fracture is an uncommon clinical fail-
ure, there can be other equally significant ramifications
of corrosion, including the release of metal ions and
1395
corrosion products [8-10,26]. Investigators have found
that the released cobalt and chromium ions can be
involved in a number of tissue reactions such as fibrinoid
necrosis, lymphocytic infiltration and aggregation, and
vasculitis, indicating some level of immune response
[8,9,26]. Corrosion products have been identified in
periprosthetic tissues, eliciting a similar response to that
of metal ion release, in addition to increasing third body
wear—both of which can lead to implant loosening
[8,27]. Other problems involving corrosion at a modular
interface include troublesome disengagement or failure
to disengage mating surfaces during revision surgery.
Fraitzl and colleagues reported on a series of 22 S-ROM
modular hips, of which 7 stem-sleeve pairs could not be
disengaged intra-operatively due to a “corrosion cold
weld,” forcing the otherwise unnecessary revision of a
well fixed S-ROM femoral sleeve [12].
An important limitation of this retrospective study is
that all devices were retrieved as a result of a revision
and may not accurately represent the entire population
of S-ROM components; there exists a large number of
S-ROM devices that remain in service and appear to be
performing well [28-30]. There are limitations asso-
ciated with using a surgeon-reported patient activity
level and not having patient weight consistently
available. The effect of implant positioning and proper
sizing was not evaluated in this study due to the lack of
x-rays; such information may provide additional insight
with respect to the damage modes described herein.
In summary, while the use of modular devices in total
hip arthroplasty is beneficial to the surgeon, patient, and
implant manufacturers, it seems unlikely that micro-
motion, which conceivably starts the corrosion cascade,
will ever be entirely eliminated. This study indicates that
there is room for improvement with respect to optimi-
zation of modular surfaces, choice of implant sizing, and
surgical technique that can mitigate negative conse-
quences associated with modularity.
Acknowledgments
The authors' would like to thank the participating
surgeons for their contribution of retrievals used in this
study. The authors' would also like to thank Todd Smith;
Distinguished Research Fellow, DePuy Orthopaedics, for
providing information relating to femoral head carbon
concentration as well as his valuable comments.
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 Stem Fracture and Corrosion in Modular Hips  Huot Carlson et al 1396.e1

Table 1. Patient Data for Corresponding Retrieved S-ROM Table 1. (continued)

Component Duration Patient
Duration Patient (Months) Reason for Retrieval Age * Sex * Weight (lbs) *
(Months) Reason for Retrieval Age * Sex * Weight (lbs) * 139.9 Subsidence/loose/aseptic 66 M 210
11 Subsidence/loose/aseptic NA NA NA loosening
loosening 120.6 Subsidence/loose/aseptic 78 M NA
15.2 Infection/sepsis 72 M 107 loosening
2.3 Subsidence/loose/aseptic 81 F 150 22.6 Subsidence/loose/aseptic 51 M NA
loosening loosening
89.1 Subsidence/loose/aseptic 64 F 150 12.9 Infection/sepsis 72 F NA
loosening 42.9 Dislocation/instability 68 F NA
31.6 Unknown 51 M 150 45.8 Fracture of implant 68 F 150
7.4 Infection/sepsis 59 M NA 52.5 Unknown 82 M NA
4.9 Dislocation/instability 36 M 260 45.5 Fracture of implant 60 F 173
22.6 Subsidence/loose/aseptic 77 M 205 12.6 Subsidence/loose/aseptic 53 M 200
loosening loosening
15.9 Infection/sepsis 41 M NA 60.9 Polywear 74 F NA
105 Subsidence/loose/aseptic 78 M NA 8.6 ALVAL † 67 F 125
loosening 182.9 Fracture of implant 71 F NA
22.8 Dislocation/instability 61 F NA 10.1 ALVAL † NA F NA
104.7 Dislocation/instability 37 NA NA 5 Dislocation/instability 60 M 195
0.4 Fracture of bone NA F NA NA Subsidence/loose/aseptic 76 M 225
106.8 Subsidence/loose/aseptic 50 F NA loosening
loosening NA Unknown 34 M NA
63.7 Subsidence/loose/aseptic 57 F NA 10.8 Infection/sepsis NA F NA
loosening NA Subsidence/loose/aseptic 65 F NA
17.7 Subsidence/loose/aseptic 56 M NA loosening
loosening 20.7 Infection/sepsis 41 F 166
24.1 Subsidence/loose/aseptic 68 F NA 34.1 Pain 49 M NA
loosening 33.1 Subsidence/loose/aseptic 61 M NA
12.8 Subsidence/loose/aseptic 83 M NA loosening
loosening 17.7 Subsidence/loose/aseptic 45 M 148
117.6 Subsidence/loose/aseptic 76 M NA loosening
loosening 66.3 Subsidence/loose/aseptic 69 F NA
139.7 Dislocation/instability 72 F 242 loosening
24.9 Subsidence/loose/aseptic 54 M NA 56.9 Subsidence/Loose/Aseptic 69 M 180
loosening Loosening
20.4 Infection/sepsis 68 F 265 13 Dislocation/instability 38 M NA
166 Fracture of implant 62 M NA 72.3 Osteolysis 58 M 260
40.2 Pain 71 M NA 3.9 Dislocation/instability 81 M NA
138.6 Subsidence/loose/aseptic 77 F NA 28.4 Subsidence/loose/aseptic 73 M NA
loosening loosening
113 Osteolysis 87 F NA 30.5 Pain 66 M 197
44 Subsidence/loose/aseptic 53 M NA 37 Subsidence/loose/aseptic NA M NA
loosening loosening
184.9 Unknown 56 M NA 64.2 Fracture of implant 69 M 282
NA Fracture of implant NA M 205 NA Unknown 69 F NA
19 Impingement 54 F NA 41.6 Subsidence/loose/aseptic 88 M NA
72 Infection/sepsis 58 M NA loosening
49.5 Subsidence/loose/aseptic 58 F 84 10.1 Infection/sepsis 59 F NA
loosening * NA = not available.
35.7 Infection/sepsis 70 F NA † ALVAL retrieved devices possessed metal-on-metal articulations.
25.2 Malposition 56 M 195
28.3 Infection/sepsis 55 M NA
46.9 Subsidence/loose/aseptic 74 M 170
loosening
84.8 Postmortem 88 M NA
11.9 Pain 64 M NA
163.5 Dislocation/instability 36 M NA
160.7 Fracture of implant NA F NA
20.8 Dislocation/instability 79 M 222
19.9 Dislocation/instability 55 M NA
7.3 Infection/sepsis 48 M NA
14.5 Subsidence/loose/aseptic NA F NA
loosening
(continued on next page)