Australian Orthopaedic Association SIDE 1
KNEE FORM National Joint Replacement Registry
FEMORAL COMPONENTS
Place PATIENT DETAILS label here (Mark relevant box, place company labels on coloured areas or complete details by hand)
and/or NONE ☐ FEMORAL ☐ STEM ☐
if any patient details are not available on the hospital label please complete below
Company …………………………………………………………………………
Surname ……………………………………………… Female ☐ Male ☐
Prosthesis Name …………………………………………………………………………
Given Name ……………………………………………… Middle Initial……………
Cat/Ref No. …………………………………………………………………………
Address ………………………………………………
Lot No. …………………………………………………………………………
……………………………………………… Post Code ………………
Hosp Patient No. ……………………………………………… DOB ……/……/…………
Medicare No. ………………………………………… DVA No. ………………………… Company …………………………………………………………………………
(If applicable)
Prosthesis Name …………………………………………………………………………
Name of Hospital ………………………………………………… State …………………… Cat/Ref No. …………………………………………………………………………
Consultant Surgeon Code (Optional) ………………………
Lot No. …………………………………………………………………………
PLEASE COMPLETE THIS SECTION IN FULL
(COMPLETE OPERATION DATE AND MARK RELEVANT BOXES)
OPERATION DATE ………/………/………… L☐ R☐ If bilateral use TWO forms FEMORAL CEMENT NO ☐ YES ☐
See over for tibial or patella cement
PRIMARY KNEE ☐ REVISION KNEE ☐
includes removal, exchange or addition of one or more
includes primary partial or total knee replacement
components
Medial ☐ Medial ☐
UNICOMPARTMENTAL Indicate UNICOMPARTMENTAL Indicate CEMENT NAME: ………………………………………………………………………
Lateral ☐ Lateral ☐
DIAGNOSIS DIAGNOSIS (Tick more than one box if applicable) (Use company label or complete details: if more than one mix is used, use only 1 label)
Osteoarthritis……………………………………………… ☐ Loosening ……………………………………………… ☐
Rheumatoid Arthritis…………………………………… ☐ Lysis ……………………………………………………… ☐
FEMORAL SPACERS
Other Inflammatory Arthritis………………………… ☐ Infection………………………………………………… ☐ (Complete details by marking boxes)
Avascular Necrosis……………………………………… ☐ Implant Breakage specify Femoral ☐
NONE ☐
Tumour specify ………………………………………… ☐ Tibial ☐
………………………………………………………………… Patella ☐ DISTAL FEMORAL Medial ☐ Lateral ☐
Other specify……………………………………………… ☐ Fracture specify …………………………………… ☐
POSTERIOR CONDYLE Medial ☐ Lateral ☐
………………………………………………………………… Other specify ……………………………………… ☐
Please return form to Locked Bag 2 Hutt St ADELAIDE SA 5000 Please complete Side 2
KNEE FORM Australian Orthopaedic Association SIDE 2
National Joint Replacement Registry
TIBIAL COMPONENTS PATELLA COMPONENT
(Mark relevant box, place company labels on coloured areas or complete details by hand) (Mark relevant box, place company labels on coloured areas or complete details by hand)
NONE ☐ ALL-IN-ONE ☐ BASE PLATE ☐ INSERT ☐ STEM ☐ NONE ☐ YES ☐
Company ………………………………………………………………………… Company …………………………………………………………………………
Prosthesis Name ………………………………………………………………………… Prosthesis Name …………………………………………………………………………
Cat/Ref No. ………………………………………………………………………… Cat/Ref No. …………………………………………………………………………
Lot No. ………………………………………………………………………… Lot No. …………………………………………………………………………
PATELLA CEMENT NO ☐ YES ☐
Company …………………………………………………………………………
Prosthesis Name …………………………………………………………………………
CEMENT NAME: ……………………………………………………………………
Cat/Ref No. …………………………………………………………………………
(Use company label or complete details: if more than one mix is used, use only 1 label)
Lot No. …………………………………………………………………………
COMPUTER ASSISTED NO ☐ YES ☐
Company …………………………………………………………………………
Prosthesis Name ………………………………………………………………………… System used: …………………………………………………………………………………………………
Cat/Ref No. ………………………………………………………………………… …………………………………………………………………………………………………
Lot No. …………………………………………………………………………
ADDITIONAL COMMENTS (or Extra Labels)
TIBIAL CEMENT NO ☐ YES ☐
CEMENT NAME: ……………………………………………………………………
(Use company label or complete details: if more than one mix is used, use only 1 label)
TIBIAL SPACERS
(Complete details by marking boxes)
NONE ☐ BLOCKS Medial ☐ Lateral ☐
ALL SECTIONS of this form MUST be COMPLETED
WEDGES Medial ☐ Lateral ☐
SCREWS NO ☐ YES ☐ Number ………
Thank you for completing this form - For further information contact (08) 8303 3592 Completed by ……………………………… Date ……/……/………