Healthy Eating for Elective Major Orthopedic Surgery: Quality, Quantity, and Timing.

Improvements to enhanced recovery pathways in orthopedic surgery are reducing the time that patients spend in the hospital, giving an increasingly vital role to prehabilitation and/or rehabilitation after surgery. Nutritional support is an important tenant of perioperative medicine, with the aim to integrate the patient's diet with food components that are needed in greater amounts to support surgical fitness. Regardless of the time available between the time of contemplation of surgery and the day of admission, a patient who eats healthy is reasonably more suitable for surgery than a patient who does not meet the daily requirements for energy and nutrients. Moreover, a successful education for healthy food choices is one possible way to sustain the exercise therapy, improve recovery, and thus contribute to the patient's long-term health. The expected benefits presuppose that the patient follows a healthy diet, but it is unclear which advice is needed to improve dietary choices. We present the principles of healthy eating for patients undergoing major orthopedic surgery to lay the foundations of rational and valuable perioperative nutritional support programs. We discuss the concepts of nutritional use of food, requirements, portion size, dietary target, food variety, time variables of feeding, and the practical indications on what the last meal to be consumed six hours before the induction of anesthesia may be together with what is meant by clear fluids to be consumed until two hours before. Surgery may act as a vital "touch point" for some patients with the health service and is therefore a valuable opportunity for members of the perioperative team to promote optimal lifestyle choices, such as the notion and importance of healthy eating not just for surgery but also for long-term health benefit.

CycLing and EducATion (CLEAT): protocol for a single centre randomised controlled trial of a cycling and education intervention versus standard physiotherapy care for the treatment of hip osteoarthritis.

BACKGROUND: Osteoarthritis (OA) is a chronic degenerative joint disorder for which there is no known cure. Non-surgical management for people with mild-to-moderate hip OA focuses mainly on alleviating pain and maximising function via the National Institute for Health and Care Excellence (NICE) recommended combination of education and advice, exercise, and, where appropriate, weight loss. The CHAIN (Cycling against Hip pAIN) intervention is a group cycling and education intervention conceived as a way of implementing the NICE guidance. METHODS: CycLing and EducATion (CLEAT) is a pragmatic, two parallel arm, randomised controlled trial comparing CHAIN with standard physiotherapy care for the treatment of mild-to-moderate hip OA. We will recruit 256 participants referred to the local NHS physiotherapy department over a 24-month recruitment period. Participants diagnosed with hip OA according to NICE guidance and meeting the criteria for GP exercise referral will be eligible to participate. Primary outcome is the difference in Hip Disability and Osteoarthritis Outcome Score (HOOS) function, daily living subscale between those receiving CHAIN and standard physiotherapy care. Secondary outcomes include performance-based functional measures (40 m walking, 30s chair stand and stair climb tests), ability for patient to self-care (patient activation measure) and self-reported health-related resource use including primary and secondary care contacts. The primary economic endpoint is the number of quality adjusted life years (QALYs) at 24 weeks follow-up. The study is funded by the National Institute for Health Research, Research for Patient Benefit PB-PG-0816-20033. DISCUSSION: The literature identifies a lack of high-quality trials which inform on the content and design of education and exercise in the treatment of patients with hip OA and explore cost-effectiveness. CLEAT is a pragmatic trial which seeks to build further evidence of the clinical benefits of the CHAIN intervention compared to standard physiotherapy care within a randomised, controlled trial setting, and examine its cost-effectiveness. TRIAL REGISTRATION NUMBER: ISRCTN19778222. Protocol v4.1, 24th October 2022.

Patient-rated satisfaction and improvement following hip and knee replacements: Development of prediction models.

RATIONALE: Effective preoperative assessments of determinants of health status and function may improve postoperative outcomes. AIMS AND OBJECTIVES: We developed risk scores of preoperative patient factors and patient-reported outcome measures (PROMs) as predictors of patient-rated satisfaction and improvement following hip and knee replacements. PATIENTS AND METHODS: Prospectively collected National Health Service and independent sector patient data (n = 30,457), including patients' self-reported demographics, comorbidities, PROMs (Oxford Hip/Knee score (OHS/OKS) and European Quality of Life (EQ5D index and health-scale), were analysed. Outcomes were defined as patient-reported satisfaction and improvement following surgery at 7-month follow-up. Univariable and multivariable-adjusted logistic regressions were undertaken to build prediction models; model discrimination was evaluated with the concordance index (c-index) and nomograms were developed to allow the estimation of probabilities. RESULTS: Of the 14,651 subjects with responses for satisfaction following hip replacements 564 (3.8%) reported dissatisfaction, and 1433 (9.2%) of the 15,560 following knee replacement reported dissatisfaction. A total of 14,662 had responses for perceived improvement following hip replacement (lack of improvement in 391; 2.7%) and 15,588 following knee replacement (lack of improvements in 1092; 7.0%). Patients reporting poor outcomes had worse preoperative PROMs. Several factors, including age, gender, patient comorbidities and EQ5D, were included in the final prediction models: C-indices of these models were 0.613 and 0.618 for dissatisfaction and lack of improvement, respectively, for hip replacement and 0.614 and 0.598, respectively, for knee replacement. CONCLUSIONS: Using easily accessible preoperative patient factors, including PROMs, we developed models which may help predict dissatisfaction and lack of improvement following hip and knee replacements and facilitate risk stratification and decision-making processes.

Using Gait Analysis to Evaluate Hip Replacement Outcomes-Its Current Use, and Proposed Future Importance: A Narrative Review.

Total hip replacement (THR) is one of the most common elective orthopaedic operations. However, evidence suggests that despite postoperative pain improvements, aspects of longer-term physical performance, such as walking ability, do not reach the levels expected when compared to the general population. Walking is best assessed by using gait analysis. This review aims to explain the concept of gait analysis, its use to evaluate THR outcomes, and its proposed future importance when evaluating new technologies proposed to improve functional recovery in individuals undergoing THR surgery. Furthermore, this review discusses the advantages and challenges of gait analysis in THR patients and provides recommendations for future work.

A cycling and education intervention for the treatment of hip osteoarthritis: A quality improvement replication programme.

OBJECTIVES: The Cycling against Hip Pain programme is a 6-week exercise and education treatment pathway for people with hip osteoarthritis. Preliminary results of the Cycling against Hip Pain programme found significant improvements in clinical and patient-reported outcome measures for patients referred from primary care. This article evaluates the effectiveness of the changes made to the pathway in a quality improvement replication programme. METHODS: The replicated Cycling against Hip Pain programme was delivered between February 2018 and September 2019 in a region of England with a high percentage of adults aged over 65 years. All participants were referred from the orthopaedic outpatient department of the funding hospital (secondary care). The programme was delivered at a local leisure centre and combined 30 min of education on osteoarthritis with 30 min of progressive static cycling, once a week for 6 weeks. RESULTS: The participants on the replicated Cycling against Hip Pain programme did not differ from the original cohort in terms of age or pre-programme weight, however, presented with worse hip symptoms at baseline. Consistent with the findings from the original cohort, participants demonstrated significant improvements to their Oxford Hip Score, 30-s chair stand performance, Timed Up and Go score, Hip Osteoarthritis Outcome Score function and pain, EQ5D health rating, EQ5D-5L score and pain at rest and on weight bearing. In addition, participants reported an increase in knowledge, confidence and motivation to exercise. CONCLUSION: A 6-week cycling and education intervention for the treatment of hip osteoarthritis provided benefits to function, pain and quality of life for patients referred from secondary care. These results are consistent with findings from patients who were referred from primary care and further support the potential of the pathway in the conservative management of hip osteoarthritis.

A Single-Centre Feasibility Randomised Controlled Trial Comparing the Incidence of Asymptomatic and Symptomatic Deep Vein Thrombosis Between a Neuromuscular Electrostimulation Device and Thromboembolism Deterrent Stockings in Post-Operative Patients Recovering From Elective Total Hip Replacement Surgery.

BACKGROUND: Total hip replacement is recognised as a major risk factor for deep vein thrombosis (DVT). The aim of this study was to investigate the feasibility of using a novel neuromuscular electrical stimulation device (NMES) for DVT prevention in patients recovering from elective hip replacement surgery. METHODS: Twenty-eight patients undergoing total hip replacement were randomised to receive postoperative treatment with either the NMES device or compression stockings continually from post-surgery until discharge (day 4). The primary outcome measure was the presence of symptomatic or asymptomatic DVT at 48 hours post-surgery and on the day of discharge from hip replacement surgery, as assessed by Duplex ultrasound. Secondary outcomes included hemodynamic responses to the devices, lower limb oedema, sit-to-stand and timed-up-and-go (TUG) scores, and hip range of motion. RESULTS: In the compression stockings group, two cases of asymptomatic DVT were identified by Duplex ultrasound at 48 hours post-surgery. No cases were found in the NMES group. Patients in the NMES group demonstrated a general trend of a decrease in leg volume from post-surgery to discharge, whereas leg volume largely remained static for the compression stockings group. In addition, positive hemodynamic effects were found in favour of the NMES group in the non-operated leg. The change in TUG scores also favoured the NMES group (NMES: 150 ± 152%, compression stockings: 363 ± 257% (p=0.03)), whereas no differences in sit-to-stand scores or hip range of motion were observed. CONCLUSIONS: This study supports the feasibility of NMES as an alternative mechanical prophylaxis worn in the postoperative phase until discharge and provides important findings for clinicians considering novel mechanical prophylaxis options.

Self-Management of Hip Osteoarthritis Five Years After a Cycling and Education Treatment Pathway.

The Cycling against Hip Pain (CHAIN) programme is a six-week cycling and education treatment pathway for people with hip osteoarthritis. Preliminary results demonstrated significant improvements in clinical and patient-reported outcome measures following the course. Whilst the benefits of exercise for osteoarthritis are often reported in the short term, less is known about the long-term effects for this patient group. This study explores whether participants continued to self-manage their hip osteoarthritis five years after completing the course. A cross-sectional survey was conducted to collect data from participants who completed the CHAIN programme between October 2013 and February 2015 (n = 96). Questionnaires were sent by post in April 2019, and then non-responders were followed up again four weeks later. Eighty-three (87%) participants responded to the survey. Five years (range 4-6) after completion of a six-week cycling and education programme, 37 (45%) participants had not returned to their general practitioner for further treatment of their hip pain, and 47 (57%) had not pursued surgical intervention. All participants were still engaged in at least one physical activity per week and many reported that they had purchased a bike (29%), joined a gym (30%) or cycled regularly (indoor cycling 25%, outdoor cycling 24%). Eighty (96%) participants reported an increase in knowledge of self-managing their symptoms. The findings from this study suggest that many patients are motivated to self-manage their hip osteoarthritis, five years following a six-week cycling and education treatment pathway that encourages lifestyle change.

Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations.

Background and purpose - There is a large volume of heterogeneous studies across all Enhanced Recovery After Surgery (ERAS®) components within total hip and total knee replacement surgery. This multidisciplinary consensus review summarizes the literature, and proposes recommendations for the perioperative care of patients undergoing total hip replacement and total knee replacement with an ERAS program.Methods - Studies were selected with particular attention being paid to meta-analyses, randomized controlled trials, and large prospective cohort studies that evaluated the efficacy of individual items of the perioperative treatment pathway to expedite the achievement of discharge criteria. A consensus recommendation was reached by the group after critical appraisal of the literature.Results - This consensus statement includes 17 topic areas. Best practice includes optimizing preoperative patient education, anesthetic technique, and transfusion strategy, in combination with an opioid-sparing multimodal analgesic approach and early mobilization. There is insufficient evidence to recommend that one surgical technique (type of approach, use of a minimally invasive technique, prosthesis choice, or use of computer-assisted surgery) over another will independently effect achievement of discharge criteria.Interpretation - Based on the evidence available for each element of perioperative care pathways, the ERAS® Society presents a comprehensive consensus review, for the perioperative care of patients undergoing total hip replacement and total knee replacement surgery within an ERAS® program. This unified protocol should now be further evaluated in order to refine the protocol and verify the strength of these recommendations.

Enhanced Recovery After Surgery: Concepts and Application to Total Shoulder Replacement.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) focuses on optimizing each element on a treatment pathway and encouraging the patient to actively engage in his or her recovery and rehabilitation. It requires collaboration across a multidisciplinary team and has been successful in improving patient outcomes, length of stay (LOS), and costs for a wide range of surgical procedures, including musculoskeletal surgeries such as total hip and total knee replacement. PURPOSE: To examine the application of ERAS concepts to total shoulder replacement (TSR) surgery. METHODS: Hospital Episode Statistics (HES) in England on LOS for TSR surgery were examined, and a review of literature on the use of ERAS concepts in TSR was undertaken. RESULTS: Analysis of HES data suggested scope for improvement in reducing LOS. A review of the literature found some evidence of the use of ERAS concepts, particularly in multimodal pain management. CONCLUSIONS: Future research is now required for ERAS procedure-specific components for TSR surgery.

A preoperative education class reduces length of stay for total knee replacement patients identified at risk of an extended length of stay.

OBJECTIVE: To establish whether attendance at an education class prior to total hip or knee replacement surgery as part of an enhanced recovery after surgery pathway could decrease length of hospital stay. METHODS: A single-site, retrospective cohort study comparing length of stay in hospital for patients who attended and did not attend an education class prior to hip or knee replacement surgery. Patients were stratified into 3 groups according to the predicted likelihood of an extended inpatient hospital stay using the Risk Assessment Predictor Tool. RESULTS: Mean length of stay reduced by 0.37 days for patients who received hip replacement (n = 590) (95% confidence interval (95% CI) -0.74, -0.01, p = 0.05) and by 0.77 days for patients who underwent knee replacement (n = 643) (95% CI -1.23, -0.31, p = 0.001) following attendance at a preoperative education class. Patients undergoing knee replacement who were considered at high risk of an extended hospital stay stayed, on average, 2.59 days less in hospital after attending the class (mean length of stay: 4.52 (standard deviation (SD) 1.26) vs 7.11 (SD 4.18) days (95% CI -4.62, -0.54, p < 0.02). CONCLUSION: This study supports the inclusion of a preoperative education session in this context for both hip and knee replacement procedures, and indicates that this may be most beneficial for patients undergoing knee replacement who are at risk of an extended length of stay.

Does Neuromuscular Electrical Stimulation Improve Recovery Following Acute Ankle Sprain? A Pilot Randomised Controlled Trial.

AIM: Following soft tissue ankle injury, patients are often referred for out-patient physiotherapy and present symptoms including pain, reduced range of movement and function, and oedema. In this study, we assess the use of a neuromuscular electrical stimulation (NMES) device as an adjunctive therapy to reduce oedema in patients recovering from grade I and II ankle sprains. METHODS: This was a single-centre, pilot randomised controlled study, recruiting patients referred to physiotherapy following an ankle sprain. Participants presenting with oedema were randomised to one of two treatment groups: (1) the current standard of care and (2) the current standard of care plus NMES use. Participants were identified in an emergency department and referred to a physiotherapy department for treatment 1 to 5 days following the injury and returned to clinic 7 days later. RESULTS: Twenty-two participants completed the study and had full data sets for analysis (11 in each group). Mean volumetric displacement was reduced in the intervention group in comparison to the standard care group (P = .011); however, there were no between-group differences in figure of eight measurements, function or pain scores. The device was well tolerated, with no device-related adverse events recorded. CONCLUSIONS: In this pilot, randomised controlled trial, NMES was well tolerated by patients following ankle sprain and demonstrated statistically significant improvements in oedema reduction as measured by fluid displacement. No other changes were observed. Further work will need to confirm the clinical significance and effect on longer term recovery post-ankle sprain.

A review of the evolution of robotic-assisted total hip arthroplasty.

INTRODUCTION: Total hip arthroplasty (THA) is currently a very successful operation but continues to evolve as we try to perfect techniques and improve outcomes for our patients. Robotic hip surgery (RHS) began with the 'active' ROBODOC system in the 1980s. There were drawbacks associated with the original ROBODOC and most recently, the MAKO robot was introduced with early promising results. AIM: The aim of this paper is to provide an up-to-date review surrounding this area and discuss the pros and cons of this technique. METHODS: A literature review searching Medline, Embase, Ovidsp, Cochrane library, pubmed database and google scholar was performed searching keywords including: 'Robotic hip surgery', 'Robotic orthopaedic surgery', 'Computer assisted hip surgery', 'robotic arthroplasty', and 'computer assisted orthopaedic surgery'. CONCLUSION: Robotic hip surgery aims to tackle the limitations of the human factor in surgery by promising reproducible and reliable methods of component positioning in arthroplasty surgery. However, as orthopaedic surgeons, we must critically appraise all new technology and support the use providing there is sound robust evidence backing it.

Can the introduction of Enhanced Recovery After Surgery (ERAS) reduce the variation in length of stay after total ankle replacement surgery?

BACKGROUND: Enhanced Recovery After Surgery (ERAS) has been successfully adopted across a range of procedures. This study explores whether there is scope to improve length of stay (LOS) for total ankle replacement surgery (TAR) in the UK by implementing ERAS pathways. METHODS: Hospital Episode Statistics (HES) data (April 2015/March 2016) on LOS for TAR were analysed. A literature search was then carried out to examine whether there were any publications on outpatient TAR and/or the use of ERAS protocols. RESULTS: Mean observed LOS was 3.3days (range 0-17.3) days. Case mix-adjusted expected LOS range was 2.0-5.7 days. It is likely that the wide observed LOS range is due to differences in local processes and pathways. Two papers were found by the literature search. CONCLUSIONS: TAR should aim to be outpatient surgery as the literature, and data demonstrating scope for improvement in LOS, suggest this should be possible.

A feasibility randomised controlled trial to evaluate the effectiveness of a novel neuromuscular electro-stimulation device in preventing the formation of oedema following total hip replacement surgery.

AIM: The aim of this feasibility study was to investigate the potential role of a novel neuromuscular electrical stimulation (NMES) device in preventing the formation of oedema following total hip replacement (THR). METHODS: Successive primary THR patients were recruited into a randomised controlled trial. Participants were randomised to wear either the NMES device or compression stockings continually from post-surgery until discharge.The main outcome measure was presence of lower limb oedema, assessed by taking measurements of the circumference of the ankle, knee and thigh on the operated leg and non-operated leg, pre-operatively, post-operatively, at two days post-operatively and every day until discharge. Secondary objectives were to compare adverse events, the presence of asymptomatic and symptomatic deep vein thrombosis (DVT) and device tolerability between groups. RESULTS: Data from 40 participants were analysed (NMES (n = 20), compression stockings (n = 20)). The NMES group had significantly less oedema and the device was found to be tolerable and safe. CONCLUSION: The results of this study suggest that the NMES is a safe and well tolerated alternative to compression stockings, which should be considered by clinicians seeking the additional benefit of reducing post-operative oedema. In addition the NMES device should be considered as part of a DVT prophylaxis.

A cycling and education programme for the treatment of hip osteoarthritis: a quality improvement study.

Osteoarthritis of the hip is associated with pain, stiffness and limitations to activities of daily living. The aims of this quality improvement project were to introduce a service developed to promote the self-management of hip osteoarthritis through exercise and education and to assess the impact of the programme on pain, function and quality of life. The service was a six-week cycling and education programme and 119 participants took part. Statistically significant improvements were found for Oxford Hip Scores (Mean (SD) change 4.14, 95%, CI 3.02, 5.25, p < 0.001); Sit-to-stand scores (mean change 3.06, 95%, CI 2.33, 3.79, p < 0.001); EQ5D-5L Utility (mean change 0.06, 95%, CI 0.03, 0.09, p < 0.001); EQ5D VAS (mean change 7.05, 95%, CI 4.72, 9.39, p < 0.001); pain on weight-bearing (WB) (mean change 1.56, 95%, CI 0.77, 2.36, p < 0.001), HOOS function (median change (IQR) 7.35, 1.84 to 19.12, p < 0.001) and TUG test (median change 1.11, 0.31 to 2.43, p < 0.001). Participants reported improvements in pain and function; increased confidence in managing hip pain and an increase in motivation to exercise. These findings were supported by a patient and public involvement forum who suggested extending the programme to eight weeks. These results suggest that the service has potential in the management of hip osteoarthritis.

Enhanced recovery after surgery (ERAS) and its applicability for major spine surgery.

This article examines the relevance of applying the Enhanced Recovery after Surgery (ERAS) approach to patients undergoing major spinal surgery. The history of ERAS, details of the components of the approach and the underlying rationale are explained. Evidence on outcomes achieved by using the ERAS approach in other orthopaedic and complex surgical procedures is then outlined. Data on major spinal surgery rates and current practice are reviewed; the rationale for using ERAS in major spinal surgery is discussed, and potential challenges to its adoption are acknowledged. A thorough literature search is then undertaken to examine the use of ERAS pathways in major spinal surgery, and the results are presented. The article then reviews the evidence to support the application of individual ERAS components such as patient education, multimodal pain management, surgical approach, blood loss, nutrition and physiotherapy in major spinal surgery, and discusses the need for further robust research to be undertaken. The article concludes that given the rising costs of surgery and levels of patient dissatisfaction, an ERAS pathway that focuses on optimising clinical procedures by adopting evidence-based practice and improving logistics should enable major spinal surgery patients to recover more quickly with lower rates of morbidity and improved longer-term outcomes.

A review of virtual reality based training simulators for orthopaedic surgery.

This review presents current virtual reality based training simulators for hip, knee and other orthopaedic surgery, including elective and trauma surgical procedures. There have not been any reviews focussing on hip and knee orthopaedic simulators. A comparison of existing simulator features is provided to identify what is missing and what is required to improve upon current simulators. In total 11 hip replacements pre-operative planning tools were analysed, plus 9 hip trauma fracture training simulators. Additionally 9 knee arthroscopy simulators and 8 other orthopaedic simulators were included for comparison. The findings are that for orthopaedic surgery simulators in general, there is increasing use of patient-specific virtual models which reduce the learning curve. Modelling is also being used for patient-specific implant design and manufacture. Simulators are being increasingly validated for assessment as well as training. There are very few training simulators available for hip replacement, yet more advanced virtual reality is being used for other procedures such as hip trauma and drilling. Training simulators for hip replacement and orthopaedic surgery in general lag behind other surgical procedures for which virtual reality has become more common. Further developments are required to bring hip replacement training simulation up to date with other procedures. This suggests there is a gap in the market for a new high fidelity hip replacement and resurfacing training simulator.

Older patients have the most to gain from orthopaedic enhanced recovery programmes.

BACKGROUND: Between August 2007 and May 2009, 2128 consecutive patients underwent either primary hip or knee joint replacement surgery at our institute on an enhanced recovery pathway. We aimed to investigate the potential benefits of this pathway in patients over the age of 85 years. METHODS: Data extracted from Hospital Episode Statistics were analysed. This data are prospectively collected and independently collated. RESULTS: In all patients median length of stay was reduced when compared with both our own data before the introduction of the pathway (6 to 4 days) and national averages over the same time period for both hip and knee replacements (5 to 4 days). Difference in length of stay was most pronounced in the group of patients aged 85 years and over (9 to 5 days for total hip replacement and 8 to 5 days for total knee replacement). Nearly all patients were discharged directly home (97.4%). Readmission rates were over 45% lower in patients aged 85 and over when compared with national averages (5.2 vs. 9.4%). CONCLUSIONS: This is the first series in the literature to assess the role of enhanced recovery pathways in the very elderly. This study not only shows that successful fast track rehabilitation can be achieved in the very elderly population undergoing elective joint replacement surgery, but that it is this cohort of vulnerable patients who have the most to gain from such multidisciplinary recovery programmes.

Failure of closed reduction after dislocation of Austin Moore hemiarthroplasty: an analysis of risk factors a 6-year follow-up study.

The aim of this study was to determine the factors associated with failure of closed reduction of dislocated Austin Moore hemiarthroplasty for subcapital neck of femur fracture. There were 44 (1.8%) cases of dislocation for a 6-year period. There were 28 females and 12 males, and mean age was 85.6 years. Thirty-two patients (80%) had redislocations, and 13 patients (40%) required 2 or more closed reductions. Twenty-eight patients subsequently had a Girdlestone arthroplasty. Dementia and a previous failed closed reduction were associated with a higher failure rate (P = .03 and .04, respectively). Failed close reduction patients also had a higher 6-month mortality rate (P = .04). Closed reduction after Austin Moore hip dislocation has a higher failure rate significantly in patients with dementia and are associated with a higher mortality rate. We believe closed reduction should be avoided in these groups of patients, and Girdlestone procedure was considered after initial first dislocation.

A novel technique for the removal of well-fixed cementless, large-diameter metal-on-metal acetabular components.

Removing well-fixed cementless acetabular components can be a challenge for every orthopedic surgeon involved in revision hip arthroplasty. Forceful removal of such components often leads to acetabular bone loss and compromises reimplantation of a new socket. Instruments like the Explant Acetabular Cup Removal System (Zimmer, Warsaw, Ind) are developed to avoid such issues. We report a novel technique, cementing a polyethylene liner inside the uncemented metal-on-metal shell and using systems such as the Explant to safely extract it without the need for matching large-diameter heads. We successfully used this technique on 3 occasions and recommend its use.