Arthroplasty registries have played a key role in the treatment of patients with various joint diseases and conditions since their conception. Swedish hip and knee arthroplasty registries were initiated in late 1970's. The main aim of registries was to create feedback to surgeons. During the last two decades with introduction of patient reported outcomes, data from registries have been increasingly used to compare caregivers and to improve quality of health care. According to the Swedish Hip Arthroplasty Register (SHAR) Sahlgrenska University Hospital had been underperforming during years 2006–2012. In order to improve the outcomes a systematic data driven approach using local and national registries, based on value based management was undertaken.

Representatives from all categories of healthcare staff and patients were invited to join a newly initiated group. The group was asked to define which measurement that contributed most to improve healthcare. Data from SHAR and local registries were used and seventeen different areas of improvement were identified. Several workgroups were initiated.

Between years 2013 and 2017 there was an increase of 60% in the annual volume of elective THAs. The length of stay decreased from 6.4 days to 1.8 days. Satisfaction with outcome of surgery increased from 76% to 90%. Adverse events decreased from 28% to 10%. The risk of re-operations within 2 years decreased from 2.4% to 1.9%.

Data from a national and a local registry were used to identify and implement changes in a large university hospital. Engaging member of staff and creating a graphical tool for continuous feedback drastically improved the quality of care whilst increasing the availability of hip replacements and reducing costs. This project demonstrates the power of registry data and a patient centered approach in engaging staff and improving healthcare.

During the last decade primary total hip arthroplasty surgery (THA) has increased with 30% in Sweden. Current law guarantees the patient a right to treatment within 90 days. The public health system has had difficulties meeting the increasing demand. Therefore, in 2012 a systematic review of the patients planned for THA was initiated at Sahlgrenska University Hospital's joint replacement unit. In late 2013 the value-based health care (VBHC) management was introduced in our unit.

In 2012 a systematic approach based on the Fast-Track concept was implemented in the joint replacement unit. In 2013 a workgroup consisting of health care professionals involved in the treatment of THA patients was created to improve chosen outcome parameters.

During 2011–2016 the number of elective THA has increased from 317 to 486. The cost per patient has decreased from 75,000 SEK to 65,000 SEK. Length of stay has decreased from 5.9 days to 2.5 days. Satisfaction with outcome of surgery one year after THA increased from 76% to 88%. The number of adverse events decreased from 29% to 11%. Number of re-operations within 2 years decreased from 2,7% to 1,9%.

Fast-Track and VBHC management was initially received with modest enthusiasm in our unit, and was regarded as means to increase production whilst possibly endanger the well-being of the patients. By using continuous feedback using the data collected it was possible to effectively communicate to patients and caregivers that the patients benefitted from the implementation.

VBHC primary aim is to improve patient outcomes and synergetically improve cost and process measurements. This should be appealing to both caregivers and administrators.

Focusing on improvement of outcomes after THA combined with VBHC management has contributed to improvement in quality of care and availability of treatment whilst decreasing cost per patient.

Malalignment and cement mantle quality have been implicated in loosening of the Charnley stem [2]. Several types of cemented prosthesis have adopted a modern insertion technique, which has not been available for the Charnley stem. We implemented a new technique for insertion of the Charnley stem via the Hardinge approach including a distal centralizer, broaches and specific entry into the femoral canal via the piriformisfossa, and compared it to the old technique for alignment of the stem and cement mantle quality.

Material and methods: Forty-two patients (34 women) operated with an old technique were compared with forty-nine patients (39 women) with the modern technique. All patients were operated through the Hardinge lateral approach, with primary hemiprosthesis by residents. Post-operative anteroposterior and true lateral radiographs were taken and evaluated for cementing quality [1], mantle thickness in the 14 Gruen zones, and alignment of the femoral stem in both planes.

Results: For the Barrack classification there was 9 grade A with the new technique, compared to none with the old (p< 0.0001, Table 1), and only 1 grade B with the old technique. The cement mantle thickness was more uniform (p< 0.0001), and the mean thickness was higher with the new technique for zones 1-3, 5-10 and 12 compared to the old technique. Alignment as measured in the lateral plane by the mean anteroposterior angle was 5.2° with the old technique, compared to 2.2° for the new technique (p=0.0001). In the frontal plane there was no difference.

Discussion: A modern insertion technique for the Charnley stem gave a much better cementing quality, better cement mantle uniformity and a thicker mantle in the critical zones, and more neutral alignment of the stem. As poor alignment and thin or absent cement mantle has been implicated in loosening the results should hopefully confer into longer survival.

New prosthesis designs should be compared to a standard implant in randomized studies evaluated by radiostereometric analysis (RSA). The Unique customized prosthesis (UCP) is a newly developed concept for fitting uncemented prosthesis to the exact internal shape of the proximal femur [1]. We evaluated the new UCP design with the null hypothesis that this implant would be no more stable than a standard cemented implant.

Material and methods: 38 patients, mean age 51.6 years (31–65) were randomized to a UCP HA coated femoral stem or an Elite Plus (DePuy) cemented stem. All patients were implanted with a Duraloc (DePuy) uncemented cup except one patient with a protrusio who was primary impaction grafted with a cemented cup. Most patients received a Zirconium head, and all heads were 28 mm. The femoral stems were fitted with 3 tantalum balls and 4–10 tantalum balls were implanted in the femur during operation. RSA pictures were taken postoperatively, after 6 and 12 months.

Results: The Elite Plus stem rotated more into retroversion after 6 and 12 months (0.79° versus 0.31° after 12 months, P< 0.05). Nearly all of this rotation took place during the first 6 months. The Elite Plus stem migrated medially while the UCP migrated laterally (0.04 mm medially versus 0.03 mm laterally, P=0.06). The Elite Plus stem also migrated more distally than the UCP (0.17 mm versus −0.06 mm, P=0.055).

Discussion: Customized implants were more stable than the cemented Elite Plus prosthesis. Compared to other results with the Elite Plus rotations and migrations were small in this study [2]. Initially all patients had good clinical results, and only by long time follow up any clinical differences due to the small differences in stability as measured by RSA can be found.

Malalignment and cement mantle quality have been implicated in loosening of the Charnley stem [2]. We implemented a new technique for insertion of the Charnley stem (Hardinge approach) including a distal centralizer, broaches and speciþc entry into the femoral canal via the piriformis fossa, and compared it to the old technique for alignment of the stem and cement mantle quality.

Material and methods: Forty-two patients (old technique) were compared with forty-two patients operated with the modern technique. Residents operated all patients with primary hemiarthroplasty. Post-operative antero-posterior and true lateral radiographs were taken and evaluated for cementing quality [1], mantle thickness in the 14 Gruen zones, and alignment of the femoral stem.

Results: For the Barrack classiþcation there was 9 grade A with the new technique, compared to none with the old (p< 0.0001). The cement mantle was more uniform (p< 0.0001), and the mean thickness was higher with the new technique for zones 1–3, 5–10 and 12. Alignment in the lateral plane was 5.2û with the old technique, compared to 2.2û for the new technique (p=0.0001).

Discussion: A modern insertion technique for the Charnley stem gave a much better cementing quality, better cement mantle uniformity and a thicker mantle in the critical zones, and more neutral alignment of the stem. As poor alignment and thin or absent cement mantle has been implicated in loosening the results should hopefully confer into longer survival.