Canadian Joint Replacement Registry - Hip Replacement Data Collection Form

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For CIHI use only
Unique Identifier
CANADIAN JOINT REPLACEMENT REGISTRY
Addressograph
Hip Replacement Data Collection Form
Surgeon First Name
Surgeon Last Name
If no, please complete only surgeon first/last name and hospital name,
Has Patient Consent Been Obtained?
Yes
No
and forward to CIHI.
Patient First Name
Middle Initial
Patient Last Name
Provincial Health Card Number
Province Code
Birth Date
Home Postal Code
Y
Y
Y
Y
M
M
D
D
Gender
Patient's Height (cm)
Weight (kg)
Male
Female
Hospital Chart Number
Hospital Province
Hospital Name _______________________________________________________________________________________________________________________________
Admission Date
Surgery Date
(If different from
surgery date)
Y
Y
Y
Y
M
M
D
D
Y
Y
Y
Y
M
M
D
D
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Referral Date
Wait Time Information
(New Patients Only)
Y
Y
Y
Y
M
M
D
D
Date of First
Date of Decision for
Consult (New
Surgery (All Patients)
Patients Only)
Y
Y
Y
Y
M
M
D
D
Y
Y
Y
Y
M
M
D
D
Please Complete This Form by Checking (
) the Appropriate Box(es)
If bilateral, complete ONE form PER SIDE
Side (Location)
Unilateral
Bilateral
Right
Left
Right
Left
Check ONE only:
Type of
Replacement
Primary
R1
R2
R3
>R3
Excision (not a revision)
Check MOST RESPONSIBLE diagnosis to involved hip:
Diagnosis
Degenerative OA
Inflammatory Arthritis
Post Traumatic OA
Osteonecrosis
Grouping
(for primary
Childhood Hip Problem
Old Hip Fracture
Acute Hip Fracture
Tumour
replacement only)
Other _____________________________
Infection
Check ALL that apply to involved hip:
Reason(s) for
Revision
Aseptic Loosening
Infection—Single Stage
Infection—Two Stage
Poly Wear
Osteolysis
Instability
Implant Fracture
Bone Fracture
N/A or
Other
__________________________
Pain of Unknown Origin
Leg length discrepancy
Check ALL that apply to involved hip:
Previous
Operations
Fracture Fixation
Surface Replacement
Pelvic Osteotomy
Femoral Osteotomy
None or
Arthrodesis
Resection Arthroplasty
Hemiarthroplasty
Total Hip Arthroplasty
Other ______________________________
Check APPROACH:
Surgical
Approach
Smith/Peterson
Anterolateral
Posterolateral
Direct Lateral
2-Incision
Other ________________
Minimally Invasive (MIS)?
Yes
No
Special
Techniques
Trans-trochanteric
Extended Trochanteric
Other __________________________
None or
(includes trochanteric slide)
Will antibiotics be administered prophylactically?
Antibiotic Use
Yes
No
If yes, duration?
≤24 hours
>24 hours
Will DVT prophylaxis be given in hospital?
DVT Prevention
Yes
No
If yes, check ALL that apply:
Warfarin
LMW Heparin
ASA
SC Heparin
Other ____________________________
Pneumatic Stockings
Foot Pump
O.R.
Environment
Check ALL that apply:
Laminar Air Flow
No Laminar Air Flow
Body Exhaust
Ultraviolet
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Hip Form 2005

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