Creating Efficiency in the O.R. with Streamlined Instrument Sets

Clinical Contributor

Matthew R. Price, MD
Ellis & Badenhausen Orthopaedics, PSC
Louisville, KY

The number of total joint replacements is growing rapidly, and the current trend suggests that the number of total joints performed will double by 2030.1 As the population ages in the United States, and the older generations graduate to more advanced stages of arthritis, the need for joint arthroplasty surgery will expand. In addition, the transition to outpatient total joint arthroplasties over the past five years has caused a shift toward shortened hospital stays and increased outpatient procedures. In 2017, only 15 percent of joint replacements were performed in the outpatient setting, and current estimates suggest that by 2026 that number will be closer to 50 percent.2

Considering these statistics, we answered the following questions regarding the implementation of the Exactech ExacSETS into our hospital and ambulatory surgery settings and cannot overstate the opportunities it afforded.

How did the O.R. experience change from the standard setup to the two-tray setup?

I operate in two different settings—an Ambulatory Surgery Center (ASC) and traditional hospital surgical suites. In the hospital setting, the rooms are typically larger and more spacious. While it is an advantage to conserve space in any setting, there is a difference in space saving in a hospital versus an ASC. Orthopedic surgery requires a great deal of instrumentation, and the room configurations are oftentimes more complicated and more cluttered than other service lines. With that in mind, most hospitals accommodate orthopedic services with larger rooms.  However, in an ASC setting, room size and maneuverability are usually confined. While an extra table or mayo stand in a hospital O.R. may not affect the space allocation, it would absolutely affect the available space in an ASC setting.

With the two-tray ExacSETS, we have been able to go from two large back tables to one large back table (Figures 1 and 2). When accounting for surgical side space, in addition to the scrub tech and fellow, this modification makes a small O.R. feel much larger.

Figure 1. One table room set-up using ExacSETS.

Figure 2. View of one table set-up using an ExacSETS tray.

Did you feel that you had to compromise anything from your standard surgical flow?

Actually, we felt the exact opposite. The flow seemed to be more efficient, and the time from room breakdown to opening felt much easier. Some systems require four to six pans to be opened for each case (Figure 3). With the switch to the ExacSETS, the room staff almost immediately noticed a difference. While it might not seem like a big difference to the surgeon waiting in the lounge for the room to be opened, our ASC staff was ecstatic to open only two pans for each case (Figure 4). When we transferred the ExacSETS to the hospital setting, the staff took notice as well.

Figure 3. Six-tray instrument system.

Figure 4. Two-tray ExacSETS kit.

Needless to say, the number of trays opened can make a vast difference in the room morale and workload to the staff. Our scrub techs and room nurses were excited about the decrease in trays being opened. I didn’t appreciate the numbers until one of my scrub techs noted that on a five-case day, we drastically cut the opening time down possibly because of a decrease in about 10 to 20 pans. Over the course of a day, those increments of time add up.

Was there a learning curve for you or your O.R. staff?

Honestly, not really. The pans are stacked a bit differently than the standard tray sets, but we quickly figured out that the instruments we needed were all available. The reamer sizes for a total hip range from 44mm to a 60mm. Head sizes range from 28mm to 40mm, with all plus and minus sizes available. In addition, all stem sizes in each grouping are available in standard and extended options. It’s a wonder we haven’t done this sooner.

Did you notice a difference in your Sterile Processing Department (SPD)?

Our SPD may have noticed the biggest difference. In addition to processing total joint tray sets, they also prepare and arrange other service lines. The task can be daunting, and the amount of work is demanding. Making sure the instruments are scrubbed, washed, and cleaned takes an enormous amount of time and effort. And that doesn’t include sterilization time. It was immediately obvious that our SPD staff preferred the two pan ExacSETS. The difference between preparing a two-tray system versus a four- to six-tray system is significant not only for the day of surgery, but also when preparing for the next day’s cases.

Overall, what did you experience as the benefits of using ExacSETS for your practice?

As an owner in an ASC, the cost savings is the biggest difference when comparing ExacSETS to the competition. The cost of preparing a tray of instruments includes scrubbing, washing, and sterilizing. That doesn’t include the overhead associated with the upkeep for sterile processors, employee salaries and benefits, and the cost of chemical supplies. It has been estimated that the cost to sterilize one pan can be anywhere from $125 to $200 per tray. If we take the median of the expected cost at $150 per tray, used for 200 joints per year, the average cost savings would be $60,000 a year for a two-tray system versus a four-tray system for a total hip. When comparing the same savings for a six-tray total knee system, the savings are $120,000 per year. Those are real numbers that can significantly reduce the overhead of running an ACS.

In the future, I believe that one of the largest responsibilities for surgeons will be cost containment. Reducing overhead costs and increasing O.R. efficiency could be accomplished using the ExacSETS for total hip and knee arthroplasties.


  1. Singh JA, Yu S, Chen L, Cleveland JD. Rates of Total Joint Replacement in the United States: Future Projections to 2020–2040 Using the National Inpatient Sample. The Journal of Rheumatology September 2019,46(9)1134-1140;org/10.3899/jrheum.170990
  2. Armocida F, Hazen B, Samii N. Moving toward success with outpatient total joint replacement surgeries. Becker’s ASC Review. September 2019. https://www.beckersasc.com/orthopedics-tjr/moving-toward-success-with-outpatient-total-joint-replacement-surgeries.html?em=mrpric02@gmail.com