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