Canadian Joint Replacement Registry - Knee Replacement Data Collection Form Page 2

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CANADIAN JOINT REPLACEMENT REGISTRY
KNEE REPLACEMENT DATA COLLECTION FORM
Unicompartmental Prosthesis?
Affix sticker(s) or catalogue and lot
Femoral
Manufacturer
number beside the specific component.
See Legend
Component
Yes
No
Do not include stickers for screws.
Below
If yes,
Replaced?
Femoral
Sticker for Femoral Component
Medial
Lateral
Patellofemoral
Component
Yes
Cemented?
Yes
No
If Cemented:
No
Porosity Reduction:
Yes
No
If Cementless, Check ALL that apply:
Porous In-growth
H. A. Coated
Press-fit
Unicompartmental Prosthesis?
Tibial
Manufacturer
Sticker(s) for Poly (Insert)
Poly Insert
Component
Yes
No
If yes,
Medial
Lateral
Patellofemoral
Replaced?
All Polyethylene?
Yes
No
Yes
Mobile Bearing?
Yes
No
Cemented?
Yes
No
Sticker(s) for Tibial Base Plate
If Cemented:
No
Tibial
Porosity Reduction?
Yes
No
Base Plate
If Cementless, Check ALL that apply:
Porous In-growth
Screws?
Yes
No
H.A. Coated
Screws?
Yes
No
Trabecular Metal
Screws?
Yes
No
PCL Retaining Or
PCL Sacrificing__________
Standard
Post & Cam
Constrained
Medial Pivot
Deep Dished
Hinged
Medial Pivot
Patellar
Manufacturer
Sticker for Patellar Component
Cemented?
Component
Yes
No
Patellar
Component
Resurfaced?
Yes
Type:
Inset
Onlay
No
Modular Stem
Femoral
Tibial
Manufacturer
Femoral Stem
Sticker(s) for Modular Femoral Stems
Stems
Yes
Cemented
No
Cementless
Tibial Stem
Sticker(s) for Modular Tibial Systems
Metal
Femoral
Tibial
Augments
Augments
Yes
Metal
No
Trabecular metal
Cement
For each item, Check ONE only:
Sticker for Cement Type
Details
Cement Name:
Versabond
Simplex
Zimmer
CMW
Cement
Other
____________________
Palacos
Osteobond
Cerafix
Used?
Antibiotics Added by Manufacturer?
Yes
No
Yes
Antibiotics Added by Surgeon?
Yes
No
If Yes, Antibiotic Name:
Tobramycin
Vancomycin
Gentamicin
Erythromycin
Other
No
Mixing Method:
Vacuum-mixed
Centrifuge
Manually Mixed
Bone Graft
Check ALL that apply:
Used—Femur
Autograft
Allograft
Bone Graft Substitute
Yes
Iliac crest
Local bone
Other
Structural
No
Strut/Onlay
Morselized
Bone Graft
Check ALL that apply:
Used—Tibial
Autograft
Allograft
Bone Graft Substitute
Yes
Iliac crest
Local bone
Other
Structural
No
Strut/Onlay
Morselized
Legend of
01 Biomet
03 J&J/DePuy
05 Zimmer
07 Smith & Nephew Richards
99 Other
Manufacturer Codes:
02 Ceraver
04 Sulzer/Centerpulse
06 Wright Medical
08 Stryker/Osteonic/Howmedica
Page 2 of 2
Knee Form 2005
Formulaire disponible en français

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