title: Large-diameter total hip arthroplasty modular heads require greater assembly forces for initial stability.
abstract: OBJECTIVE
  Modular junctions are ubiquitous in contemporary hip arthroplasty. The head-trunnion junction is implicated in the failure of large diameter metal-on-metal (MoM) hips which are the currently the topic of one the largest legal actions in the history of orthopaedics (estimated costs are stated to exceed $4 billion). Several factors are known to influence the strength of these press-fit modular connections. However, the influence of different head sizes has not previously been investigated. The aim of the study was to establish whether the choice of head size influences the initial strength of the trunnion-head connection.
  
  
  METHODS
  Ti-6Al-4V trunnions (n = 60) and two different sizes of cobalt-chromium (Co-Cr) heads (28 mm and 36 mm; 30 of each size) were used in the study. Three different levels of assembly force were considered: 4 kN; 5 kN; and 6 kN (n = 10 each). The strength of the press-fit connection was subsequently evaluated by measuring the pull-off force required to break the connection. The statistical differences in pull-off force were examined using a Kruskal-Wallis test and two-sample Mann-Whitney U test. Finite element and analytical models were developed to understand the reasons for the experimentally observed differences.
  
  
  RESULTS
  36 mm diameter heads had significantly lower pull-off forces than 28 mm heads when impacted at 4 kN and 5 kN (p < 0.001; p < 0.001), but not at 6 kN (p = 0.21). Mean pull-off forces at 4 kN and 5 kN impaction forces were approximately 20% larger for 28 mm heads compared with 36 mm heads. Finite element and analytical models demonstrate that the differences in pull-off strength can be explained by differences in structural rigidity and the resulting interface pressures.
  
  
  CONCLUSIONS
  This is the first study to show that 36 mm Co-Cr heads have up to 20% lower pull-off connection strength compared with 28 mm heads for equivalent assembly forces. This effect is likely to play a role in the high failure rates of large diameter MoM hips.Cite this article: A. R. MacLeod, N. P. T. Sullivan, M. R. Whitehouse, H. S. Gill. Large-diameter total hip arthroplasty modular heads require greater assembly forces for initial stability. Bone Joint Res 2016;5:338-346. DOI: 10.1302/2046-3758.58.BJR-2016-0044.R1.
authors: University of Bath, Claverton Down Rd, Bath, North East Somerset BA2 7AY, UK.
authors: A R
authors: AR
authors: MacLeod
authors: Southmead Hospital, Department of Trauma and Orthopaedics, North Bristol NHS Trust, Southmead Way, Bristol, BS10 5NB, UK.
authors: N P T
authors: NP
authors: Sullivan
authors: University of Bristol, Musculoskeletal Research Unit, Southmead Hospital, Bristol, UK, BS10 5NB, UK.
authors: M R
authors: MR
authors: Whitehouse
authors: University of Bath, Claverton Down Rd, Bath, North East Somerset BA2 7AY, UK r.gill@bath.ac.uk.
authors: H S
authors: HS
authors: Gill
keywords: Connection; Head Size; Pull-off; Strength; Taper; Trunnion