In the current healthcare environment, cost containment has become more important than ever. Perioperative services are often scrutinized as they consume more than 30% of North American hospitals’ budgets. The procurement, processing, and use of sterile surgical inventory is a major component of the perioperative care budget and has been recognized as an area of operational inefficiency. Although a recent systematic review supported the optimization of surgical inventory reprocessing as a means to increase efficiency and eliminate waste, there is a paucity of data on how to actually implement this change. A well-studied and established approach to implementing organizational change is Kotter's Change Model (KCM). The KCM process posits that organizational change can be facilitated by a dynamic 8-step approach and has been increasingly applied to the healthcare setting to facilitate the implementation of quality improvement (QI) interventions. We performed an inventory optimization (IO) to improve inventory and instrument reprocessing efficiency for the purpose of cost containment using the KCM framework. The purpose of this quality improvement (QI) project was to implement the IO using KCM, overcome organizational barriers to change, and measure key outcome metrics related to surgical inventory and corresponding clinician satisfaction. We hypothesized that the KCM would be an effective method of implementing the IO. This study was conducted at a tertiary academic hospital across the four highest-volume surgical services - Orthopedics, Otolaryngology, General Surgery, and Gynecology. The IO was implemented using the steps outlined by KCM (Figure 1): 1) create coalition, 2) create vision for change, 3) establish urgency, 4) communicate the vision, 5) empower broad based action, 6) generate general short term wins, 7) consolidate gains, and 8) anchor change. This process was evaluated using inventory metrics - total inventory reduction and depreciation cost savings; operational efficiency metrics - reprocessing labor efficiency and case cancellation rate; and clinician satisfaction. The implementation of KCM is described in Table 1. Total inventory was reduced by 37.7% with an average tray size reduction of 18.0%. This led to a total reprocessing time savings of 1333 hours per annum and labour cost savings of $39 995 per annum. Depreciation cost savings was $64 320 per annum. Case cancellation rate due to instrument-related errors decreased from 3.9% to 0.2%. The proportion of staff completely satisfied with the inventory was 1.7% pre-IO and 80% post-IO. This was the first study to show the success of applying KCM to facilitate change in the perioperative setting with respect to surgical inventory. We have outlined the important organizational obstacles faced when making changes to surgical inventory. The same KCM protocol can be followed for optimization processes for disposable versus reusable surgical device purchasing or perioperative scheduling. Although increasing efforts are being dedicated to quality improvement and efficiency, institutions will need an organized and systematic approach such as the KCM to successfully enact changes. For any figures or tables, please contact the authors directly

Escalating health care expenditure worldwide is driving the need for effective resource decision-making, with medical practitioners increasingly making complex resource decisions within the context of patient care. Despite raising serious legal and ethical issues in practice, this has attracted little attention in Australia, or internationally. In particular, it is unknown how orthopaedic surgeons perceive their obligations to the individual patient, and the wider community, when rationing care, and how they reconcile competing obligations. This research explores legal and ethical considerations, and resource allocation by Australian orthopaedic surgeons, as a means of achieving public health cost containment driven by macro-level policy and funding decisions. This research found that Australian orthopaedic surgeon's perceptions, and resource allocation decision making, can be explained by understanding how principles of distributive justice challenge, and shift, the traditional medical paradigm. It found that distributive justice, and challenges of macro level health policy and funding decisions, have given rise to two new medical paradigms. Each which try to balance the best interests of individual patients with demands in respect of the sustainability of the health system, in a situation where resources may be constrained. This research shows that while bedside rationing has positioned the medical profession as the gate keepers of resources, it may have left them straddling an increasingly irreconcilable void between the interests of the individual patient and the wider community, with the sustainability of the health system hanging in the balance

Opinions about the treatment of Perthes' disease vary widely. However there is no disagreement about the need for containment during fragmentation stage to create an optimum biomechanical environment for remodelling of femoral head. Types of containment may vary. Younger children do well irrespective of the method of containment. Older children usually require surgical containment. The present study was aimed at evaluating the results of different methods of surgical containment in different age group and identifying specific factors that alter the final outcome and prognosis. 107 cases were reviewed retrospectively. 21 cases were excluded due to lack of records. 86 hips were available for clinical and radiological evaluation. 31 patients were under 7 years and required Varus osteotomy (VO). 55 patients were above 7 years. VO was performed in 30 hips and Shelf containment was done in 25. Case notes were reviewed for demographic details, surgical details and clinic letters. Radiographs were reviewed for Herring's grading, Stulberg staging, containment indices, centre edge angle, lateral pillar height, Mose index, neck shaft angle and shelf width. In all patients, there was an improvement in pre-operative symptoms and summated range of motion, especially abduction. Good functional and radiological outcome was seen in age group < 7 years. In older children, outcome was good to satisfactory with Herring grade B. Stulberg grading worsened with advancing age and Herring grade C, irrespective of the method of containment. Persistence of varus neck shaft angle and trochanteric overgrowth were significant problems with VO. Although all containment indices improved with Shelf group, Stulberg grading remained poor in most patients. The lateral pillar classification and age strongly correlate with final outcome. Herring group C had the least favourable result. Stulberg staging remained poor in older children irrespective of the method of containment

Aim. It still remains unclear whether postoperative antibiotic treatment is advantageous in presumed aseptic revision-arthroplasties of the hip (rTHA) and knee (rTKA) with unexpected-positive-intraoperative-cultures (UPIC). The aim of this study was to evaluate if there is a difference in the septic and/or aseptic re-revision rate in patients with or without postoperative antibiotics. Method. In this retrospective propensity-score (PS) matched cohort-study we compared the re-revision rate and the microbiological spectrum in rTHA and rTKA treated with (AB-Group; n=70) and without (non-AB-Group; n=70) antibiotic treatment in patients with UPIC. Baseline covariates for PS-matching were type of revision, sex, Body-Mass-Index, age, Surgical-Site-Infection-Score, American-Society-of-Anesthesiologists-Classification, serum C-reactive-protein. All patients received routine antibiotic prophylaxis, but empiric AB treatment was started only in patients in the AB-Group. Post-operative treatment was decided on an individual basis according to the preference of the surgeon and the infectious disease specialist for a minimum duration of two weeks. In total, 90 rTHA (45 AB-Group, 45 in non-AB-Group) patients with UPICs and 50 rTKA (25 AB-Group, 25 in non-AB-Group) were included in the study. There was no significant variation in patient demographics. Results. After a median follow-up of 4.1 (IQR: 2.9-5.5) years after rTHA and rTKA, there was no higher re-revision rate (p=0.813) between the AB-group 10/70 (14.3%), and the non-AB-group 11/70 (15.7%). In the AB group, 4.3% (3/70) of patients underwent revision due to septic complications compared to 5.7% (4/70) in the non-AB group (survival log-rank: p=0.691). In total, 30/70 (42.9%) of patients in the AB-group and 23/70 (32.9%) of patients in the non-AB group were diagnosed as having an “infection likely” according to the PJI diagnostic criteria of EBJIS (p=0.223). All UPICs comprised low virulent microorganisms and were considered as a contaminant. In total, 68/70 (97.1%) of the patients in the AB-group received a dual antibiotic treatment for a mean duration of 41 (IQR: 23.5-56.5) days. Conclusion. Postoperative antibiotic treatment did not result in a decreased re-revision rate compared to non-antibiotic treatment in patients with UPIC in presumed aseptic rTHA and rTKA. UPICs with pathogens are likely to be a containment and therefore the classification of “infection likely” according to the EBJIS definition can be safely ignored

Most cost containment efforts in public health systems have focused on regulating the use of hospital resources, especially operative time. As such, attempting to maximize the efficiency of limited operative time is important. Typically, hospital operating room (OR) scheduling of time is performed in two tiers: 1) master surgical scheduling (annual allocation of time between surgical services and surgeons) and 2) daily scheduling (a surgeon's selection of cases per operative day). Master surgical scheduling is based on a hospital's annual case mix and depends on the annual throughput rate per case type. This throughput rate depends on the efficiency of surgeons’ daily scheduling. However, daily scheduling is predominantly performed manually, which requires that the human planner simultaneously reasons about unknowns such as case-specific length-of-surgery and variability while attempting to maximize throughput. This often leads to OR overtime and likely sub-optimal throughput rate. In contrast, scheduling using mathematical and optimization methods can produce maximum systems efficiency, and is extensively used in the business world. As such, the purpose of our study was to compare the efficiency of 1) manual and 2) optimized OR scheduling at an academic-affiliated community hospital representative of most North American centres. Historic OR data was collected over a four year period for seven surgeons. The actual scheduling, surgical duration, overtime and number of OR days were extracted. This data was first configured to represent the historic manual scheduling process. Following this, the data was then used as the input to an integer linear programming model with the goal of determining the minimum number of OR days to complete the same number of cases while not exceeding the historic overtime values. Parameters included the use of a different quantile for each case type's surgical duration in order to ensure a schedule within five percent of the historic overtime value per OR day. All surgeons saw a median 10% (range: 9.2% to 18.3%) reduction in the number of OR days needed to complete their annual case-load compared to their historical scheduling practices. Meanwhile, the OR overtime varied by a maximum of 5%. The daily OR configurations differed from historic configurations in 87% of cases. In addition, the number of configurations per surgeon was reduced from an average of six to four. Our study demonstrates a significant increase in OR throughput rate (10%) with no change in operative time required. This has considerable implications in terms of cost reduction, surgical wait lists and surgeon satisfaction. A limitation of this study was that the potential gains are based on the efficiency of the pre-existing manual scheduling at our hospital. However, given the range of scenarios tested, number of surgeons included and the similarity of our hospital size and configuration to the majority of North American hospitals with an orthopedic service, these results are generalizable. Further optimization may be achieved by taking into account factors that could predict case duration such as surgeon experience, patients characteristics, and institutional attributes via machine learning

Introduction. Total shoulder replacement is a successful treatment for gleno-humeral osteoarthritis. However, components loosening and painful prostheses, related to components wrong positioning, are still a problem for those patients who underwent this kind of surgery. CT-based intraoperative navigation system is a suitable option to improve accuracy and precision of the implants as previously described in literature for others district. Method. Eleven reverse shoulder prostheses were performed at Modena Polyclinic from October 2018 to April 2019 using GPS CT-based intraoperative navigation system (Exactech, Gainsville, Florida). In the preoperative planning, Walch classification was used to assess glenoid type. The choice of inclination of the glenoid component, the screw length, as well as the inclination of the reamer was study and recorded using specific software using the CT scan of shoulder of each patient (Fig.1, Fig.2). Intraoperative and perioperative complications were recorded. Three patients were male, eight were female. Mean age was 72 years old (range 58=84). Three glenoid were type B2, six cases were B1, two case were type C1. Results. In all cases treated by reverse shoulder prostheses we had obtain good functional results at preliminary follow up. Eight degree posterior augment was used in seven case. Planned version was 0° in eight case, an anti-version of 3° was planned in the other three cases. Final reaming was as preoperatively planned in all cases except one. Mean surgical time was 71 minutes (range 51–82). One case of coracoid rupture has been reported. In all cases the system worked in proper manner without failures, no case of infection was reported. Discussion. It is well known as the more accurate placement of the glenoid led to enhanced long-term survivorship of the implant and decrease complication rates in RSTA. Our first experience with GPS navigation system has been satisfied. Good components’ positioning has been reached in all cases, without deviation from the preoperative planning. Pre-operative preparation using software has been always respected except in one case in which we decided to ream 1mm less to avoid excessive bone loss. In 3 case we decide to increase glenoid anti-version to allow a good cage containment in the scapula. No failure of the system has been recorded, with a little increase in the surgical time respect to traditional surgeries performed in our institute. The first case performed reported coracoid fracture, probably due to lack of experience in coracoid tracker positioning. It is very important to set the surgical theatre and the position of the patient in order to make the coracoid tracker visible for the computer. Screw positioning and length is decisively improved with GPS system compared with traditional implant. The most important advantage is to avoid the malposition of the glenoid component, solving problems like loosening or restriction in shoulder range of motion. We believe that a final cross check between preoperative planning and final control of the prostheses implanted, should be used in the future, but by now the GPS navigation system is a useful way to improve our surgery, especially in difficult cases. For any figures or tables, please contact the authors directly

Acetabular cages are necessary when an uncemented or cemented cup cannot be stabilised at the correct anatomic level. Impaction grafting with mesh for containment of bone graft is an alternative for some cases in centers that specialise in this technique. At our center we use three types of cage constructs:. (A). Conventional cage ± structural or morselised bone grafting. This construct is used where there is no significant bleeding host bone. This construct is susceptible to cage fatigue and fracture. This reconstruction is used in young patients where restoration of bone stock is important. (B). Conventional cage in combination with a porous augment where contact with bleeding host bone can be with the ilium and then by the use of cement that construct can be unified. The augment provides contact with bleeding host bone and if and when ingrowth occurs, the stress is taken off the cage. (C). Cup Cage Construct – in this construct there must be enough bleeding host bone to stabilise the ultra-porous cup which functions like a structural allograft supporting and eventually taking the stress off the cage. This construct is ideal for pelvic discontinuity with the ultra-porous cup, i.e., bridging and to some degree distracting the discontinuity. If, however, the ultra-porous cup cannot be stabilised against some bleeding host bone, then a conventional stand-alone cage must be used. In our center the cup cage reconstruction is our most common technique where a cage is used, especially if there is a pelvic discontinuity

Acetabular cages are necessary when an uncemented or cemented cup cannot be stabilised at the correct anatomic level. Impaction grafting with mesh for containment of bone graft is an alternative for some cases in centers that specialise in this technique. At our center we use three types of cage constructs –. Conventional cage ± structural or morselised bone grafting. This construct is used where there is no significant bleeding host bone. This construct is susceptible to cage fatigue and fracture. This reconstruction is used in young patients where restoration of bone stock is important. Conventional cage in combination with a porous augment where contact with bleeding host bone can be with the ilium and then by the use of cement that construct can be unified. The augment provides contact with bleeding host bone and if and when ingrowth occurs, the stress is taken off the cage. Cup Cage Construct – in this construct there must be enough bleeding host bone to stabilise the ultra-porous cup which functions like a structural allograft supporting and eventually taking the stress off the cage. This construct is ideal for pelvic discontinuity with the ultra-porous cup, i.e., bridging and to some degree distracting the discontinuity. If, however, the ultra-porous cup cannot be stabilised against some bleeding host bone, then a conventional stand-alone cage must be used. In our center the cup cage reconstruction is our most common technique where a cage is used, especially if there is a pelvic discontinuity

Acetabular cages are necessary when an uncemented or cemented cup cannot be stabilised at the correct anatomic level. Impaction grafting with mesh for containment of bone graft is an alternative for some cases in centers that specialise in this technique. At our center we use three types of cage constructs –. (A). Conventional cage ± structural or morselised bone grafting. This construct is used where there is no significant bleeding host bone. This construct is susceptible to cage fatigue and fracture, This reconstruction is used in young patients where restoration of bone stock is important. (B). Conventional cage in combination with a porous augment where contact with bleeding host bone can be with the ilium and then by the use of cement that construct can be unified. The augment provides contact with bleeding host bone and if and when ingrowth occurs, the stress is taken off the cage. (C). Cup-Cage Construct – in this construct there must be enough bleeding host bone to stabilise the ultra-porous cup which functions like a structural allograft supporting and eventually taking the stress off the cage. This construct is ideal for pelvic discontinuity with the ultra-porous cup, i.e., bridging and to some degree distracting the discontinuity. If, however, the ultra-porous cup cannot be stabilised against some bleeding host bone, then a conventional stand-alone cage must be used. In our center the cup-cage reconstruction is our most common technique where a cage is used, especially if there is a pelvic discontinuity. Acetabular bone loss and presence of pelvic discontinuity were assessed according to the Gross classification. Sixty-seven cup-cage procedures with an average follow-up of 74 months (range, 24–135 months; SD, 34.3) months were identified; 26 of 67 (39%) were Gross Type IV and 41 of 67 (61%) were Gross Type V (pelvic discontinuity). Failure was defined as revision surgery for any cause, including infection. The 5-year Kaplan-Meier survival rate with revision for any cause representing failure was 93% (95% confidence interval, 83.1–97.4), and the 10-year survival rate was 85% (95% CI, 67.2–93.8). The Merle d'Aubigné-Postel score improved significantly from a mean of 6 pre-operatively to 13 post-operatively (p < 0.001). Four cup-cage constructs had non-progressive radiological migration of the ischial flange and they remain stable

Acetabular cages are necessary when an uncemented or cemented cup cannot be stabilised at the correct anatomic level. Impaction grafting with mesh for containment of bone graft is an alternative for some cases in centers that specialise in this technique. At our center we use three types of cage constructs –. (A) Conventional cage ± structural or morselised bone grafting. This construct is used where there is no significant bleeding host bone. This construct is susceptible to cage fatigue and fracture. This reconstruction is used in young patients where restoration of bone stock is important. (B) Conventional cage in combination with a porous augment where contact with bleeding host bone can be with the ilium and then by the use of cement that construct can be unified. The augment provides contact with bleeding host bone and if and when ingrowth occurs, the stress is taken off the cage. (C) Cup Cage Construct – in this construct there must be enough bleeding host bone to stabilise the ultra-porous cup which functions like a structural allograft supporting and eventually taking the stress off the cage. This construct is ideal for pelvic discontinuity with the ultra-porous cup, i.e., bridging and to some degree distracting the discontinuity. If, however, the ultra-porous cup cannot be stabilised against some bleeding host bone, then a conventional stand-alone cage must be used. In our center the cup cage reconstruction is our most common technique where a cage is used, especially if there is a pelvic discontinuity. Acetabular bone loss and presence of pelvic discontinuity were assessed according to the Gross classification. Sixty-seven cup-cage procedures with an average follow-up of 74 months (range, 24–135 months; SD, 34.3) months were identified; 26 of 67 (39%) were Gross Type IV and 41 of 67 (61%) were Gross Type V (pelvic discontinuity). Failure was defined as revision surgery for any cause, including infection. The 5-year Kaplan-Meier survival rate with revision for any cause representing failure was 93% (95% confidence interval, 83.1–97.4), and the 10-year survival rate was 85% (95% CI, 67.2–93.8). The Merle d'Aubigné-Postel score improved significantly from a mean of 6 pre-operatively to 13 post-operatively (p < 0.001). Four cup-cage constructs had non-progressive radiological migration of the ischial flange and they remain stable

Acetabular cages are necessary when an uncemented or cemented cup cannot be stabilised at the correct anatomic level. Impaction grafting with mesh for containment of bone graft is an alternative for some cases in centers that specialise in this technique. At our center we use three types of cage constructs –. (A) Conventional cage ± structural or morsellised bone grafting. This construct is used where there is no significant bleeding host bone. This construct is susceptible to cage fatigue and fracture. This reconstruction is used in young patients where restoration of bone stock is important. (B) Conventional cage in combination with a porous augment where contact with bleeding host bone can be with the ilium and then by the use of cement that construct can be unified. The augment provides contact with bleeding host bone and if and when ingrowth occurs, the stress is taken off the cage. (C) Cup Cage Construct – in this construct there must be enough bleeding host bone to stabilise the ultra-porous cup which functions like a structural allograft supporting and eventually taking the stress off the cage. This construct is ideal for pelvic discontinuity with the ultra-porous cup, i.e., bridging and to some degree distracting the discontinuity. If, however, the ultra-porous cup cannot be stabilised against some bleeding host bone, then a conventional stand-alone cage must be used. In our center the cup cage reconstruction is our most common technique where a cage is used, especially if there is a pelvic discontinuity

Acetabular cages are necessary when an uncemented or cemented cup cannot be stabilised at the correct anatomic level. Impaction grafting with mesh for containment of bone graft is an alternative for some cases in centers that specialise in this technique. At our center we use three types of cage constructs: (A) Conventional cage ± structural or morselised bone grafting. This construct is used where there is no significant bleeding host bone. This construct is susceptible to cage fatigue and fracture. This reconstruction is used in young patients where restoration of bone stock is important; (B) Conventional cage in combination with a porous augment where contact with bleeding host bone can be with the ilium and then by the use of cement that construct can be unified. The augment provides contact with bleeding host bone and if and when ingrowth occurs, the stress is taken off the cage; (C) Cup Cage Construct – in this construct there must be enough bleeding host bone to stabilise the ultra-porous cup which functions like a structural allograft supporting and eventually taking the stress off the cage. This construct is ideal for pelvic discontinuity with the ultra-porous cup, i.e., bridging and to some degree distracting the discontinuity. If, however, the ultra-porous cup cannot be stabilised against some bleeding host bone, then a conventional stand-alone cage must be used. In our center the cup cage reconstruction is our most common technique where a cage is used, especially if there is a pelvic discontinuity

There are three major diagnoses that have been associated with early hip degeneration and subsequent hip replacement in young patients: FAI, hip dysplasia and hip osteonecrosis. I will focus mainly on the first two. Both conditions, if diagnosed early in the symptomatic patient, can be surgically treated in order to try to prevent further hip degeneration. But, what is the natural history of these disorders?. Our recent paper published this year described the natural history of hip dysplasia in a group of patients with a contralateral THA. At an average of 20 years, 70% of hips that were diagnosed at Tönnis Grade 0, had progression in degenerative changes with 23% requiring a THA at 20 years. Once the hip degeneration progressed to Tönnis 1, then 60% of hips progressed and required a THA. This natural history study demonstrates that degeneration of a dysplastic hip will occur in over 2/3 of the hips despite the limitations of activity imposed by a contralateral THA. In this same study, we were unable to detect a significant difference in progression between FAI hips and those categorised as normal. FAI damage has been commonly considered to be “motion-induced” and as such, the limitations imposed by the THA, might have limited the progression in hip damage. Needless to say, progression was seen in about half of the hips at 10 years, but very few required a THA at final follow-up. We have recently presented data on a group of young asymptomatic teenagers with FAI. At 5 years of follow-up, the group of patients with limited ROM in flexion and internal rotation, cam deformity and increased alpha angles, depicting a more severe form of disease, showed MRI evidence of progression in hip damage and worst clinical scores than a control group. This data supports our initial impressions that FAI may truly lead to irreversible hip damage. Is surgery always the option? I indicate surgery when the patient is symptomatic and has a correctable structural problem that has failed non-operative management. The data suggests that few patients improve with physical therapy, but activity modification may be an option in patients with FAI as the hip damage is mainly activity related. This may not be the case with hip dysplasia. For hip dysplasia, my current recommendations are in the form of a periacetabular osteotomy (PAO) to correct the structural problem. The procedure leads to improvement in pain as it takes care of the 4 pain generators in the dysplastic hip: the labrum, cartilage, abductors, and resultant instability. The labrum and cartilage are off-loaded with the PAO, the instability is improved by providing containment and the abductor pain is improved by improving the hip mechanics by medializing the acetabulum. I perform a hip arthroscopy prior to the PAO in the majority to treat the labrum and to perform a head neck junction osteochondroplasty, if needed. Correction of the dysplasia to a more normal hip, will improve the outcome of these hips in the long-term. For FAI, arthroscopy has become the best option for management and today is considered the gold standard. A careful review of the imaging is important prior to surgical decision making as patient selection and surgical correction is key. Poor outcomes have been seen in patients with advanced degenerative changes (joint space narrowing, femoral head damage) or in patients with incomplete correction of the deformity. Open surgical correction is an option in cases where deformity precludes an arthroscopic treatment alone

Aims

In the UK, the NHS generates an estimated 25 megatonnes of carbon dioxide equivalents (4% to 5% of the nation’s total carbon emissions) and produces over 500,000 tonnes of waste annually. There is limited evidence demonstrating the principles of sustainability and its benefits within orthopaedic surgery. The primary aim of this study was to analyze the environmental impact of orthopaedic surgery and the environmentally sustainable initiatives undertaken to address this. The secondary aim of this study was to describe the barriers to making sustainable changes within orthopaedic surgery.

We aimed to assess whether using long stem femoral components, with cemented distal fixation and proximal impaction grafting allows early patient mobilisation, reconstitution of the proximal femur and long term stability of fixation in patients with aseptic loosening and proximal femoral analysis. Over the past ten years 239 patients have been treated with an Elite Plus cemented long stem femoral implant, 33% with concomitant proximal impaction bone grafting. Many of the patients had co-morbidities. The average age at revision was 72 years (range 48 to 91). There was a slight female predominance. Fourteen percent of hips had been previously revised. Forty-eight patients were deceased and 22 were not available for follow-up; this left a cohort of 169 patients who were available for radiological and questionnaire review at an average of 4.5 years. According to the Paprosky grading for pre-operative bone loss 40% had moderate to severe bone loss (grade IIIb or IV). The Barrack grading was used to assess the cement mantle post-operatively with 65% showing good cementation. The Harris and O'Neill grades were used at final review to assess probability of loosening with only 8% being probably or definitely loose. The average Oxford Hip Score was 29. Mesh ± cables were required in a third of cases to allow adequate containment and pressurisation. It was generally felt that the long stem needed to be at least one third longer than the initial component. The re-revision rate was 1.2 with a 10 year survivorship analysis of 94%. The complication rate of almost 6% included periprosthetic fractures, dislocations, infection and mesh breakage. A long stem cemented femoral implant can be useful in bypassing proximal femoral deficiency in the appropriate patient

Protrusio acetabuli (arthrokatadysis or Otto pelvis) is a relatively rare condition associated with secondary osteoarthritis of the hip. Radiographically, protrusio acetabuli is present when the medial aspect of the femoral head projects medial to Kohler's (ilioischial) line. This results in medialization of the center of rotation (COR) of the hip. Protrusio acetabuli is typically associated with metabolic bone disease (osteoporosis, osteomalacia, Paget's disease) or inflammatory arthritis (RA or ankylosing spondylitis). Idiopathic acetabular protrusio can occur without the above associated factors however. Patients with protrusio acetabuli typically present with significant restriction of range of motion (ROM) of the hip due to femoral neck and trochanteric impingement in the deep acetabular socket and pain associated with secondary osteoarthritis (OA). Total hip arthroplasty (THA) in patients with protrusion acetabuli is more challenging than THA in patients with a normal hip COR. ROM is typically quite restricted which can compromise surgical exposure. Dislocation of the hip in the patient with a deep socket and medialised COR can be extremely difficult and associated with fracture of the femur if not carefully performed. Restoration of the hip COR to the normal more lateralised position is a principle goal of surgery. This restores more normal mechanics of the hip and has been associated with improved durability. A variety of techniques to accomplish this have been described including medial acetabular bone grafting with cemented cups, protrusio rings or porous coated cementless cups fixed with multiple screws. The latter technique has been shown to be more durable and associated with better outcomes. THA in protrusio acetabuli starts with templating of the preoperative x-rays to determine the optimal acetabular implant size and final position of the acetabular component that restores the hip COR to the normal position. Patients with protrusio acetabuli often have varus oriented femoral necks and the femur needs to be carefully templated as well to insure that an appropriate femoral component is available that will allow for restoration of the patient's anatomy. Cartilage covering the thinned medial wall needs to be carefully removed without disruption of the medial acetabular wall. The acetabulum is then carefully reamed with the goal of obtaining stable peripheral rim support of a cementless socket and at least 50% contact of the implant on good quality host bone. Unlike acetabular preparation in the normal hip, preventing the reamer from “bottoming out” is essential in order to obtain desired rim support and return of the hip COR to the normal lateralised position. When good rim support of the reamer is obtained, a trial component is placed and intraoperative x-ray obtained to confirm fit, position and restoration of hip COR. Limited addition reaming can be performed to obtain desired degree of press fit (1‐2mm) and contact with host bone. Morselised autograft from the femoral head and neck is then packed into the medial defect and reverse reamed. The cementless acetabular component is then impacted into position and fixed with screws. Weight bearing is determined by bone quality, size and containment of the medial defect, amount of contact of the cementless cup with host bone and stability of the acetabular construct. Incorporation of autograft bone in the acetabulum and stable long term fixation occurs reliably if stable initial press-fit fixation of the cementless cup is obtained. Restoration of hip COR to within 7mm of its normal location is associated with better implant survival

Cemented total hip arthroplasty has become an extremely successful operation with excellent long term results. Although showing decreasing popularity in North America, it always remained a popular choice for the elderly patients in Europe and other parts of the world. Besides optimal component orientation, a proper cementing technique is of major importance to assure longevity of implant fixation. Consequently a meticulous bone bed preparation assures the mechanical interlock between the implant component, cement and the final bone bed. Cementing the acetabular side should include preservation of the transverse acetabular ligament and clear identification of the medial wall. Medialisation and deepening of the socket are important at reaming, to ensure a containment of the cup. The contact of the cup to cancellous bone should be maximised. Either smaller reamers or 4–6mm anchoring holes can be drilled to the superior sclerosis. Smaller defects can be curettage, while larger ones might require cancellous bone grafting. Of major importance is the thoroughly pulsatile jet lavage with saline to irrigate the cancellous bone bed, to reduce fat and blood lamination. After final irrigation, before cementation, dry sponges are slightly impacted into the cavity, to dry it out. Cementation usually requires 40g of high viscosity bone cement. Immediate pressurisation of the cement into the bone bed should start after a general application time in our institution between 2.5 to 3 minutes after mixing; with either a sterile glove filled with a sponge or designated company specific pressuriser. Sustained pressurisation should be done for 1 minute. The original cup should be 3–4mm smaller than the last reamer, to ensure circumferential cement mantle. Insertion principle includes medialisation first, followed by gradual angulation of the cup. In appropriate position, a balled pressuriser maintains pressure without further moving of the implant, until cement hardening. Remnant cement can be removed with osteotomes, while remaining osteophytes should be flush with implant. Femoral Side: First the fossa pyriformis should be clearly identified, including the posterolateral entry point of the prosthesis. The femoral neck cut is usually 1.5–2cm above the minor trochanter, based on the preoperative planning and implant type. Opening of the canal is done with an awl or osteotome, followed by any blunt tipped instrument, to follow the intramedullary direction. A box osteotome opens the lateral portion of the femoral neck, gently to preserve as much cancellous bone as possible. Sequential broaching follows carefully and according to the planning, to ensure preservation of 2–3mm cancellous bone for interdigitation. Some systems might require over-broaching by one size. Trialing is done with the broach. Following, irrigation using a long nozzle pulsatile lavage, reduces the chance for fat embolism. A cement restrictor is then placed 1.5–2cm distal to the tip of the stem, to ensure an adequate cement mantle distally. A second complete pulsatile irrigation of the canal follows, to minimise bleeding, followed by a dry sponge. Cement mixing is vacuum based in the meantime, usually 60–80g. We prefer the use of low dose antibiotic laden cement in our set up. Two to three minutes after mixing, the cement is applied rapidly in a retrograde technique with a cement gun, placing the nozzle tip against the cement restrictor. The gun is “pushed” out during the application, rather than being withdrawn from the canal. Proximal pressurisation is first done by thumb, then with a proximal seal for 1 minute. The stem is inserted slowly using steady manual pressure, in the center of the cement mantle, however, should never be impacted. The stem is aligned with the previously defined lateral entry point and is held in position until the cement hardens. The desired outcome is a cement interdigitation into cancellous bone for 2–3mm and an additional mantle of 2mm pure cement

Using a computer-based quality assurance program, we analysed peri-operative data on 160 patients undergoing one-stage bilateral hip or knee arthroplasties under regional anaesthesia with routine anaesthetic monitoring and only using peripheral intravenous access for peri-operative safety. We monitored defined intra-operative adverse events such as hypotension, myocardial ischaemia, arrhythmias, hypovolaemia, hypertension and early post-operative complications. We also determined post-operative hip and knee function, and patient satisfaction with different aspects of the anaesthetic management. Those patients undergoing one-stage bilateral arthroplasties were matched according to a cross-stratification which used three variables (American Society of Anesthesiologists’ physical status scoring system, age and joint replaced) to patients undergoing unilateral hip or knee arthroplasties. Serious intra-operative adverse events were, with the exception of intra-operative hypotension, very infrequent in patients undergoing bilateral (nine adverse events) as well as unilateral arthroplasties (five adverse events). Early post-operative complications were also infrequent in both groups. However, the risks of receiving a heterologous blood transfusion (odds ratio 2.5; 95% confidence interval (CI) 1.3 to 5.0, estimated by exact conditional logistic regression) or vasoactive drugs (odds ratio 3.9; 95% CI 2.0 to 7.8) were significantly greater for patients undergoing bilateral operations. Patient satisfaction with anaesthesia was high; all patients who underwent the one-stage bilateral operation would choose the same anaesthetic technique again.