Canadian Joint Replacement Registry - Knee Replacement Data Collection Form

For CIHI use only

Unique Identifier

CANADIAN JOINT REPLACEMENT REGISTRY

Addressograph

Knee 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

Height (cm)

Weight (kg)

Male

Female

Hospital Chart Number

Hospital Province

Hospital Name _______________________________________________________________________________________________________________________________

Admission Date (if different

Surgery Date

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 Surgery

Consult (New

(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

Right

Left

Bilateral

Right

Left

Check ONE only:

Type of

Replacement

Primary

R1

R2

R3

>R3

Excision (not a revision)

Diagnosis

Check MOST RESPONSIBLE diagnosis to involved knee:

Grouping

Degenerative OA

Inflammatory Arthritis

Post Traumatic OA

Osteonecrosis

(for primary

Other ______________________________________

Infection

Tumour

Acute fracture

replacement only)

Reason(s) for

Check ALL that apply to involved knee:

Revision

Aseptic Loosening

Infection—Single Stage

Implant Fracture

Poly Wear

Instability

N/A or

Pain of Unknown Origin

Infection—Two Stage

Bone Fracture

Osteolysis

Unispacer

Other ___________________

Unresurfaced Patella

Patella Maltracking

Patella Failure

Previous

Check ALL that apply to involved knee:

Operations

Total Knee Arthroplasty

Unicompartmental Arthroplast

Tibial Osteotomy

Femoral Osteotomy

None or

Open Menisectomy

Arthroscopic Menisectomy

Patellectomy

Ligament Repair

Other _____________________________________

Fracture Fixation

Arthroscopic Debridement

Joint Deformity

Check ALL that apply to involved knee:

None or

If Any ≥15°

Varus

Valgus

Flexion contracture

Surgical

Check APPROACH:

Approach

Medial Parapatellar

Lateral Parapatellar

Intravastus

Subvastus

Other ____________________

Minimally Invasive (MIS)?

Yes

No

Check ALL that apply to involved knee:

Special Steps

Lateral Retinacular Release

Rectus Snip

Quadriceps Turndown

None or

Tubercle Osteotomy

Other _____________________________

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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Knee Form 2005