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The pre-design orientation needed to be considered in this study. In relation to the trunnion, it was important to identify the position in order to evaluate the variability of the distance between the trunnion and the head of the prosthesis. To achieve this, three dimensional (3D) models of the head, the trunnion and the head with the trunnion were performed. All models were created in Netfabb 2018 in the following steps: first the head model was created, using the reference size for a large head head size of 40 mm (that corresponds to the polyurethane cover), and the cups were positioned in the frontal view. The trunnion model was created with the same size as the cup. The trunnion, which corresponds to the shell formed on the trunnion of the prosthesis, was fixed by an hexagonal bar. The hexagonal bar was fixed in the frontal view of the head using the bolt and nut technique. The head was fixed to the hexagonal bar. When the angles between the components were obtained, the prosthesis was oriented and fixed to the pelvic side (Figure 8 and Figure 9 ) ( [Figure 10](#f02)ref-type="fig" ).


Fully-CAD-based design represents the state-of-the-art for manufacturing. This approach allows the designer to work with only the design rules for the part that have been calculated, rather than having to apply all the many design rules in a non-CAD environment to generate a part. Once the CAD model is generated and exported, the material is added by the additive manufacturing process, usually by layering the material to create a 3D-print. The benefits of fully-CAD-based design include improved safety, efficiency and ergonomics. However, fully CAD-based manufacturing also presents the designer and manufacturer with numerous technical challenges, such as part porosity and surface smoothness, with the latter in particular being a key factor in the additive manufacturing process. Fully CAD-based manufacturing also has a reliance on the CAD model, which by its nature is not perfect and requires additional generation of a CAD model from the physical prototype. This additional step in the process of fully CAD-based manufacturing can be time consuming and increases the cost of manufacturing, and hence can add to the barriers to adoption (Bakir, Sperl, & Li, 2016 ; Palant, & Gruhl, 2015 ). 3d9ccd7d82






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