One OR can be organized very swiftly in case as many variables as possible are taken out of the equation. Probably the most important aspect is OR equipment reduction. However, also standardized draping (step 2)  and retractor placement (step 4)  allow for the creation of a positive “Esy OR pulse” with parallel processing.

We work with 3 surgical team members: the surgeon, the scrub nurse and the circulating nurse or surgical assistant.

For the anesthesia team, the anesthesiologist and the anesthesia nurse collaborate together.

The reduction of instrument equipment allows for easily setting up the instrument tables in a very reproducible and standardized way, regardless of the experience of the scrub nurse. In every case, the OR instruments are positioned in the same way on the Kocher table, which is located at the foot end of the patient.
The Kocher table is positioned on the foot side of the table and contains all instruments required to conduct the first 2 parts of the procedure: capsular exposure and release. This well structured table can be easily approached by the surgeon.

Upper left: power tools for the femoral osteotomy.
Lower right: retractors with the Gripper (MedEnvision, Belgium). Knife, wooden spoon, T-handle and Langenbeck are always in the lower left corner.

One of the most important challenges was creating trays with a minimum of instrument content, but also with a structured and well organized set-up. The aim was to minimize the time and energy expenditure for the nurse to identify the correct instruments. Therefore, the trays are structured in such a way that for each part of the procedure most instruments are found in that particular tray. One tray mainly covers the OR instrumentation (1) and the other one the Implant instrumentation (2). This tray set-up allows the scrub nurse to open the trays very quickly, well organized, and with a minimum of energy expenditure both physically and mentally.

(1) Concerning the OR instrumentation
we have  along with the nursing staff critically evaluated which instruments are really necessary to safely conduct an EDA Hip procedure. We have rationalized the trays by discarding approximately 70% of our instruments from our regularly used trays . The most important challenge was to keep the weights of the trays below 8.5kg (19 pounds) to remain within the regulations for sterile tray weights. In case deemed necessary during a specific case, extra-trays can be opened. This is very rarely required in ‘regular’ primary THA cases.

The content of the ESY OR instrument tray is shown in the following figures:

From left to right upper line showing the “small” instruments: 1 instrument for prepping, 2 knives, 2 forceps, 1 scissors, 2 Kochers and 2 needle holders.

Lower line from left to right: 1 hemostat, 1 periosteal elevator, 1 curette and 1 nibbler.

The ESY  “larger” OR instruments. From top to down: 1 blunt bone hook, 1 hammer (500g), 1 femoral head caliper, 1 osteotome, 1 spoon, 2 Langenbeck and 2 Volkmann retractors.

Tissue friendly retractors  are of paramount importance for any kind of surgery in order to reduce the surgical trauma. Our ESY Retractors for the EDA Hip  have been designed with specific features: a soft tissue friendly body curvature, reduced length to fit in the ESY kit, and a flat handling end for orthostatic retractor placement. All retractors are numbered according to their sequential usage during the procedure. This facilitates a standardized usage. In order to further minimize the soft tissue trauma and OR time, it is important to hold the retractors in a stable and standardized position. During the EDA Hip procedure, a table mounted orthostatic retractor device (Gripper) is used.
In total 5 ESY retractors are  required to conduct the EDA procedure. The retractors are curved in the axial direction. The socket impactor is double curved to facilitate the procedure for more obese patients.
A chain is used to hold the calcar retractor during capsular exposure. Other instruments are the cork screw driver with a T-handle, the straight stem impactor and the straight reamer handle for the socket.
The Esy retractors are sequentially numbered which guides the team members throughout the standardized procedure. The body of every retractor is designed with a curvature in the transverse plane in order to minimize soft tissue damage. The flat ended part of the ESY retractors perfectly fits into the slot of the Gripper, which assures a stable retractor placement during the procedure.

(2)  Implant Instrumentation reduction
Standardization of the surgical technique of component preparation and insertion is of paramount importance to reduce the “Regular” Implant instrumentation set. Pre-operative templating plays an important role in order to anticipate for potential problems such as reaming for Dorr A type femurs or unusually large sized implants.The content of the Corail/Pinnacle (DepuySynthes, Warsaw) ESY instrumentation kit is shown . This covers 98% of the cases. Pinnacle socket reamers cover socket sizes from 48mm to 58mm.  The Corail stem broaches are downsized from 11 to 9 sizes discarding the 2 largest sizes.

Another key factor of efficiency is trying to reduce variability between cases. One example is the femoral dual offset broach handle. The dual offset handle has got a slight curvature in the axial and the transverse plane. In obese patients this can be helpful, in slimmer patients this is often not required. However, in order to reduce variability and tray content we use the dual offset broach handle in every case .
The dual offset broach handles are used in every case, also in slimmer patients. Similarly, the offset acetabular reamer is always used because it facilitates bikini incision surgery in obese patients. A blunt, slightly curved rat tail canal finder, a straight impactor and a calcar mill are also included in ESY implant instrument Kit.

With regards to the socket preparation, we try to recreate the anatomic center of rotation. This reduces variability in reaming. The scrub nurse measures the diameter of the femoral head with a caliper . The aim is to insert a Pinnacle socket (DepuySynthes, Warsaw) with a diameter equal to or maximum 2mm larger than the native femoral head diameter. Once the nurse has measured the native head size, the components are immediately put ready in the room (parallel processing). Reaming starts with a straight reamer because this allows the surgeon to remove the hard subchondral sclerotic bone. Once cancellous bleeding bone is visible, the offset reamer is then used . Since we under ream by 1mm relative to the final component diameter, we included only “odd diameter” graters in the ESY Kit starting from 43mm to 57mm . This covers 97.5% of cases. We do not trial for the acetabular component.