THE NORWEGIAN ARTHROPLASTY REGISTER KNEES AND OTHER JOINTS (than hips) Patient ID and date of birth:…...………………. Hospital:………………………………………… Patient’s weight:………………

Localisation:

1 Knee 6 Elbow

2 Ankle 7 Wrist4 Toe Joints:………. 8 Finger joints:………….5 Shoulder 9 Others…………………1 Right 2 LeftPrevious operation in index joint:0 No 4 Arthodesis1 Osteosynthesis 5 Synovectomy2 Osteotomy 6 Other:…………………….3 Prosthesis.Type......................……Year………..

Date of operation: ...............

Index operation is: 1 Primary op. 2 Revision

Diagnosis (primary operation):

1 Idiophatic arthrosis

2 Rheumatoid arthritis

3 Sequelae after fracture

4 Ankylosing spondylitis

5 Sequelae, ligament tear

6 Sequelae, menisceal tear

7 Acute fracture

8 Sequela, infection9 Other .............. .................................................Reasons for revision (one or more):

1 Loose prox. comp. 7 Malalignment

2 Loose distal comp. 8 Deep infection

3 Loose patella comp. 9 Fracture

4 Dislocated patella 10 Pain5 Dislocation 11 Defect polyethylene……6 Instability 12 Other…………………..Type of revision (one or more):

1 Change of distal component

2 Change of proximal component

3 Change of all components4 Change of patella component5 Change of polyethylene:…………………………6 Removal. Components:.......................................

7 Insert of patella component

8 Other: ........................…................................….

Structural bone transplant: 0 No1 Autograft 2 Allograft 3 Bone impaction prox. 4 Bone impaction distal 5 Other:………..Systemic Antibiotic prophylaxis:

0 No

1 Yes: Type……………Combinations…………..

Dosage……………….Duration, days………….

Duration of operation: ………………Peroperative complication:

0 No

1 Yes. Type:……………………………………….

KNEE Prosthesis type:

1 Tricondylar 2 Bicondylar

3 Unicondylar 4 PatellofemoralFemoral component: Name/size………………………………………….

Catalogue no:…………………………………

Stem/Stabilized/Wedge:………………………

1 Cement with antibiotic. Name: ...........................

2 Cement without antibiotic. Name: ......................

3 UncementedTibial component:

Name/size: ............................................................

Catalogue number: ................................................

Stem/Stabilized/Wedge:.…..………………………

1 Cement with antibiotic. Name: ...........................

2 Cement without antibiotic. Name: ......................

3 UncementedPatella component:

Name/type: .............................................….....

Catalogue number:.……………………….…..

Metal-back 0 No 1 Yes

1 Cement with antibiotic. Name: ...........................

2 Cement without antibiotic. Name: ......................

3 UncementedCruciate ligaments

1 Anterior, intact before operation 0 no 1 yes

2 Anterior, intact after operation 0 no 1 yes

3 Posterior, intact before operation 0 no 1 yes

4 Posterior, intact after operation 0 no 1 yes

……………………………………………………OTHER JOINTS:

Prosthesis type:

1 Total 2 Hemi 3 One-component prosthesis

Proximal component:

Name/size: ............................................................

Catalogue number: ................................................

1 Cement with antibiotic. Name: ...........................

2 Cement without antibiotic. Name: ......................

3 Uncemented

Distal component:

Name/size: ............................................................

Catalogue number: ................................................

1 Cement with antibiotic. Name: ...........................

2 Cement without antibiotic. Name: ......................

3 Uncemented

Intermediate component (e.g. caput humeri):

Name/size: ............................................................

Catalogue number: ................................................

Surgeon (who has filled in the form):

..............................................………............. (Surgeon’s name is not registered)