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Although proximal row carpectomy, wrist arthrodesis and even total wrist arthroplasty were developed to treat wrist disease using bone and cartilage of the wrist, severe and complicated bone defects caused by ferocious trauma and bone tumors remain a stubborn problem for surgeons. Development and application of the three-dimensional (3D) printing technology may provide possible solutions.

Computed tomography (CT) data of three cases with severe bone defects caused by either trauma or bone tumor were collected and converted into three-dimensional models. Prostheses were designed individually according to the residual anatomical structure of the wrist based on the models. Both the models and prostheses were produced using 3D printing technology. A preoperative design was prepared according to the models and prostheses. Then arthroplasty was performed after preoperative simulation with printed models and prostheses.

The diameter of the stem and radial medullary cavity, the direction and location of the prosthesis, and other components were checked during the preoperative design and simulation process phases. The three cases with 3D printed wrist all regained reconstruction of normal anatomy and part of the function after surgery. The average increasing Cooney score rate of Cases 2 and 3 was 133.34 ± 23.57 per cent, and that of Case 1 reached 85 per cent. The average declining rate of the Gartland and Werley Score in Cases 2 and 3 was 65.21 ± 18.89 per cent, and that of Case 1 dropped to 5 per cent in the last follow-up. The scores indicated that patients experienced pain relief and function regain. In addition, the degree of patient satisfaction improved.

3D printed wrist arthroplasty may provide an effective method for severe and complicated cases without sacrificing other bones. Personal customization can offer better anatomy and function than arthrodesis or other traditional surgical techniques.

One of the biggest challenges in the health sector is that of costs compared to economic resources and the quality of services. Hospitals register a progressive increase in expenditure due to the aging of the population. In fact, hip and knee arthroplasty surgery are mainly due to primary osteoarthritis that affects the elderly population. This study was carried out with the aim of analysing the introduction of the fast track surgery protocol, through the lean Six Sigma, on patients undergoing knee and hip prosthetic replacement surgery. The goal was to improve the arthroplasty surgery process by reducing the average length of stay (LOA) and hospital costs

Lean Six Sigma was applied to evaluate the arthroplasty surgery process through the DMAIC cycle (define, measure, analyse, improve and control) and the lean tools (value stream map), adopted to analyse the new protocol and improve process performance. The dataset consisted of two samples of patients: 54 patients before the introduction of the protocol and 111 patients after the improvement. Clinical and demographic variables were collected for each patient (gender, age, allergies, diabetes, cardiovascular diseases and American Society of Anaesthesiologists (ASA) score).

The results showed a 12.70% statistically significant decrease in LOS from an overall average of 8.72 to 7.61 days. Women patients without allergies, with a low ASA score not suffering from diabetes and cardiovascular disease showed a significant a reduction in hospital days with the implementation of the FTS protocol. Only the age variable was not statistically significant.

The introduction of the FTS in the orthopaedic field, analysed through the LSS, demonstrated to reduce LOS and, consequently, costs. For each individual patient, there was an economic saving of € 445.85. Since our study takes into consideration a dataset of 111 patients post-FTS, the overall economic saving brought by this study amounts to €49,489.35.

Three-dimensional (3D) printing is increasingly used to produce orthopaedic components for hip arthroplasty, such as acetabular cups, which show complex lattice porous structures and shapes. However, limitations on the quality of the final implants are present; thus, investigations are needed to ensure adequate quality and patients safety. X-ray microcomputed tomography (micro-CT) has been recognised to be the most suitable method to evaluate the complexity of 3D-printed parts. The purpose of this study was to assess the reliability of a micro-CT analysis method comparing it with reference systems, such as coordinate measuring machine and electron microscopy.

3D-printed acetabular components for hip arthroplasty (n = 2) were investigated. Dimensions related to the dense and porous regions of the samples were measured. The micro-CT scanning parameters (voltage – kV, current – µA) were optimised selecting six combinations of beam voltage and current.

Micro-CT showed good correlation and agreement with both coordinate measuring machine and scanning electron microscopy when optimal scanning parameters were selected (130 kV – 100 µA to 180 kV – 80 µA). Mean discrepancies of 50 µm (± 300) and 20 µm (± 60) were found between the techniques for dense and porous dimensions. Investigation method such as micro-CT imaging may help to better understand the impact of 3D printing manufacturing technology on the properties of orthopaedic implants.

The optimisation of the scanning parameters and the validation of this method with reference techniques may guide further analysis of similar orthopaedic components.

This paper seeks to analyse clinical pathways (CP) as a useful tool for the improvement of all aspects of quality in medical assistance – in this case, hip arthroplasty.

The study was carried out on patients who had undergone scheduled hip arthroplasty included in CP during the years 1999 to 2004. Data on demographics, lengths of stay, complications, process and result variables were gathered, coverage was calculated and the evolution of the indicators was compared.

A total of 487 patients were enrolled, with five leaving the pathway and with unequal coverage, leading to a maximum peak of 77 per cent in 1999. A statistically significant decrease exists in the consumption of overall stays and in the pre‐surgical stay, which dropped from a mean of 19.41 days in the pre‐pathway situation to 10.12 days in 2004 and 4.5 days pre‐surgery to 1.08 days. As a process indicator, the performance should be highlighted of post‐operation check‐up radiographies, which have been gaining high levels of compliance (p < 0.05) since 2001. The rate of complications has remained stable over the years.

Implementing the CP has meant a sustained saving of resources over the years and an improvement in the organization of work.

The decision to offer joint replacement surgery should be viewed as entering into a long‐term relationship rather than a brief encounter. The rise of consumerism allied to the expansion of general practitioner fund‐holding and implementation of the ‘Patients' Charter’ has resulted in increased pressures on outpatient clinics, and the interface between primary and secondary care is central to the development of the NHS. The NHS reforms have produced guidelines on waiting times for outpatient attendances and operations, with the emphasis on a consultant‐based service. There are, however, no such guidelines for postoperative follow‐up.

This article describes a framework for evaluating efficiency of OR procedures incorporating time measurement, personnel activity, and resource utilization using traditional industrial engineering tools of time study and work sampling.

The framework measures time using time studies of OR procedures and work sampling of personnel activities, ultimately classified as value-added or non-value-added. Statistical methods ensure that the collected samples meet adequate levels of confidence and accuracy. Resource utilization is captured through documentation of instrument trays used, defects in instruments, and trash weight and classification at the conclusion of surgeries.

A case study comprising 12 observations of total knee arthroplasty surgeries illustrates the use of the framework. The framework allows researchers to compare time, personnel, and resource utilization simultaneously within the OR setting.

The framework provides a holistic evaluation of methods, instrumentation and resources, and staffing levels and allows researchers to identify areas for efficiency improvement.

The methods presented in this article are rooted in traditional industrial engineering work measurement methods but are applied to a healthcare setting in order to efficiently identify areas for improvement including time, personnel, and processes in operating rooms.

The purpose of the paper is to measure compliance with agreed protocols for prophylactic antibiotics for five elective procedures: transurethral resection of the prostate, cholecystectomy, hysterectomy, joint arthroplasty and herniorrhaphy in two teaching hospitals.

Compliance was measured during the pre and post intervention periods by reviewing medical records.

Overall, compliance improved by 18 per cent (95 per cent CI: 12 per cent, 23 per cent) with greater improvements for transurethral resection of the prostate and hysterectomy, increasing by 27 per cent (95 per cent CI: 14 per cent, 40 per cent) and 24 per cent (95 per cent CI: 16 per cent, 32 per cent) respectively. Compliance remained low for cholecystectomy (17 per cent) and hysterectomy (25 per cent). Overall, the proportion of patients not receiving any prophylaxis where its use was indicated, declined by 6 per cent (95 per cent CI: 1 per cent, 11 per cent) from 23 per cent. The use of additional anti‐microbials that were not recommended in the protocol was high for joint arthroplasty 65 per cent and hysterectomy 71 per cent, but overall this practice declined by 8 per cent (95 per cent CI: 3 per cent, 14 per cent). Costs were reduced from $11.72 to $10.53 per patient between the pre and post intervention groups, while a complete adoption of the protocols could reduce costs by 70 per cent to $3.40. There were large variations in correct dosages and timing of antibiotics between procedural groups.

Although compliance improved there were large differences between the specialties. The adoption of preventive strategies is fundamental to providing safe patient care. The use of inappropriate antimicrobials is also an important patient safety issue that contributes to antibiotic resistance and is associated with increased costs. Introducing change in health organizations is difficult and the factors influencing successful change strategies require further study.

The paper measures and improves compliance with agreed protocols in health care intervention procedures.

The ROBODOC¹ Surgical Assistant System provides computer assisted planning and execution of bone milling for total hip arthroplasty and total knee arthroplasty procedures. One key aspect of the robotic procedure is registration, the process of transforming the robot’s milling instructions from the image coordinate system used for planning into the robot coordinate system in which the plan is executed. The first‐generation system performed registration using fiducial markers (pins) implanted in the patient. These markers present various disadvantages to patients, surgeons, and clinics. As a result, users asked for a “pinless” single surgery system. The resulting design, DigiMatch, achieves registration by matching points digitized from the bone anatomy to a three‐dimensional surface model developed from a CT scan of the bone. The DigiMatch system is currently in routine use in many clinics in Europe, and is under clinical evaluation in the USA.

The collection of complete and accurate data is an essential prerequisite of any study that aims to produce meaningful results. Much contemporary research in orthopaedic surgery has focused on proving the superiority of one implant or technique over another and relies on data which are currently being collected by various different methods. Modern joint replacement surgery is now successful with high implant survivorship at 10 and even 20 years and any new prosthetic design could be expected to result in only a modest improvement over current results. Complete follow‐up as well as optimum data collection are therefore of particular importance to detect any such benefit. Four methods commonly used for the collection of orthopaedic data were compared in this study with the aim of finding out which techniques would automatically result in the most reliable capture of complete data without the need for labour‐intensive supervision and the use of additional resources. The information obtained has been used to re‐define the audit methods for the North West Regional Arthroplasty Register.