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West Bengal Arthroplasty Society WBAS

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									                West Bengal Arthroplasty Society (WBAS)
                            Joint Replacement Registry
                             Knee Replacement Data Collection Form (K1)

1) Patient Details:
     1.   Name (Surname, Forenames)…………………………………………
     2.   Sex:       Male       Female
     3.   Age (in years)……………..
     4.   Religion:…………………………………………………………………
     5.   Address (City/Town/Village, Postcode)………………………………
     6.   Mother tongue…………………………………………………………..

2) Operation Details:
     1. Hospital:………………………………………………………………..
     2. Operation Date:(DD/MM/YY)……………………………………………
     3. Anaesthesia: GA
                     Epidural
                     Spinal
                     Regional nerve block
                     Sedation
     4. Operation Theatre:
                     Laminar Air Flow      Yes       No
                     Body exhaust         ‫ ڤ‬Yes       ‫ڤ‬No
                     Ultraviolet          ‫ ڤ‬Yes       ‫ڤ‬No
                     Other……………………………………
     5. Antibiotic use: a) Yes              No
                        b) If yes, Duration: Less than 24hrs
                                             Up to 72 hrs
                                             More than 72 hrs
                        c) Drug/s used…..…………………………………….
     6. DVT prophylaxis: None  LMWH  Heparin  Warfarin 
                            Aspirin  Other (specify)  Calf Pump 
     7. Post-op analgesia protocol (outlines):………………………………….
     ………………………………………………………………………………

3) Surgeon Details:
           1. Consultant in charge…………………………………………………..
           2. Operating surgeon…………………………………………………….
           3. Assistant surgeon (with grade)………………………………………..
4) Operation Details:

          1) Side: Left   ‫ٱ‬Right   ‫ٱ‬Bilateral (same sitting)

          2) Procedure: ‫ٱ‬Primary ‫ٱ‬Revision



                             Knee Replacement Data Collection Form (K1)
                                                                          Page 1 of 4
              West Bengal Arthroplasty Society (WBAS)
                           Joint Replacement Registry
                             Knee Replacement Data Collection Form (K1)

        3) Indication for primary (Choose most responsible for involved knee):
                sitirhtra yrotammalfni ‫ ڤ‬NVA ‫ڤ‬        AO ‫ ڤ‬evitcefni tsoP ‫ڤ‬
              rehto ‫ ڤ‬erutcarF ‫ ڤ‬ruomuT ‫ڤ‬           amuart tsoP ‫…………ڤ‬

            Indication for revision (Tick all that apply):
                 gninesool citpesA ‫ ڤ‬tcefnI ‫ ڤ‬egats eno noitcefnI ‫ڤ‬ion two stage
                erutcarF ‫ڤ‬       ytilibatsnI ‫ڤ‬      raew yloP ‫ڤ‬  eruliaf tnalpmI ‫ڤ‬
              sisyloetsO ‫ڤ‬       alletap decafrusernU ‫ ڤ‬nigiro nwonknu fo niaP ‫ڤ‬
              m ralletaP ‫ڤ‬altracking ‫ ڤ‬Patellar failure ‫ ڤ‬Failed Unicomp.
              rehtO ‫ڤ‬

        4) Type:
            latnemtrapmocinU ‫ ڤ‬yramirP detnemecnU ‫ڤ‬    yramirP detnemeC ‫ڤ‬
            olletaP ‫-ڤ‬femoral    ‫ ڤ‬Other (e.g. Hybrid)………..

        5) Previous operations on involved knee (choose all that apply):
           ymotoetsO laibiT ‫ڤ‬       ytsalporhtra latnemtrapmocinU ‫ڤ‬       RKT ‫ڤ‬
           ymotcesinem .sorhtrA ‫ڤ‬      ymotcesinem nepO ‫ڤ‬         ymotoetsO .meF ‫ڤ‬
            tnemedirbed sorhtrA ‫ڤ‬      noitaxif erutcarF ‫ڤ‬     ymotcelletaP ‫ڤ‬
           rehtO ‫ڤ‬     ymotcevonyS ‫ ڤ‬riaper tnemagiL ‫..………………ڤ‬

        6) Joint Deformity:
             fI ‫ ڤ‬erutcartnoC noixelF ‫ڤ‬      suglaV ‫ڤ‬      suraV ‫ ڤ‬any> 15°

        7) Pre op flexion:
            ‫°07< ڤ‬      °011> ‫ڤ‬    °011 ot 19 ‫ڤ‬    °09 ot 17 ‫ڤ‬

        8) Surgical Approach:
             …rehtO ‫ ڤ‬sutsavbuS ‫ ڤ‬ralletaparap .taL ‫ڤ‬         ralletaparap .deM ‫ڤ‬

        9) Minimally invasive (MIS)     ‫ ڤ‬Yes      ‫ ڤ‬No

        10) Computer assisted (CAS) ‫ ڤ‬Yes         ‫ ڤ‬No

        11) Special steps: ‫ ڤ‬None ‫ ڤ‬Lateral release ‫ ڤ‬Quads turndown
                  ..……………………rehtO ‫ڤ‬              ymotoetso elcrebuT ‫ڤ‬

        12) Bone Defects: (Select compartment with worst defect):
              Femur: ‫ ڤ‬Lateral ‫ ڤ‬Medial ‫1 > ڤ‬cm ‫ 2-1 ڤ‬cm                ‫ 2> ڤ‬cm
              Tibia: ‫ ڤ‬Lateral ‫ ڤ‬Medial ‫1 > ڤ‬cm ‫ 2-1 ڤ‬cm                ‫ 2> ڤ‬cm
5) Implant Details: (Give stickers!)
            I.Cement:




                             Knee Replacement Data Collection Form (K1)
                                                                                     Page 2 of 4
   West Bengal Arthroplasty Society (WBAS)
                Joint Replacement Registry
                 Knee Replacement Data Collection Form (K1)

        Mixing method : ‫ ڤ‬Manual    ‫ ڤ‬Vacuum     ‫ ڤ‬Centrifuge


II. Femoral component:




III. Tibial component:




IV. Tibial insert:




V. Patella:




VI. Stems:




                 Knee Replacement Data Collection Form (K1)
                                                                Page 3 of 4
             West Bengal Arthroplasty Society (WBAS)
                           Joint Replacement Registry
                             Knee Replacement Data Collection Form (K1)

           VII. Augments:




6) Bone grafting:

                                        Autograft           Allograft         Bone graft
                                                                                   Subs
                         Iliac crest    Local       Other
                                        Bone

           Structural    ‫ڤ‬              ‫ڤ‬           ‫ڤ‬       ‫ڤ‬             ‫ڤ‬

           Strut/onlay   ‫ڤ‬              ‫ڤ‬           ‫ڤ‬       ‫ڤ‬             ‫ڤ‬

           Morcelised                   ‫ڤ‬
                                        ‫ڤ‬           ‫ڤ‬       ‫ڤ‬             ‫ڤ‬




                             Knee Replacement Data Collection Form (K1)
                                                                                           Page 4 of 4

								
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