THE NORWEGIAN ARTHROPLASTY REGISTER TOTAL HIP REPLACEMENTS Patient ID and date of birth:…...………………. Hospital:…………………………………………

0 No

1 Osteosynthesis for prox. femur fracture

2 Hemiprosthesis

3 Osteotomy

4 Arthrodesis

5 Total hip prosthesis

Type: ...............................................................……..

Year: ...............................................................……..

Number of prostheses in index hip: .......................................................…………..

6 Other operations:

.....…………………. .............................................

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

1 Primary operation

Hip:

1 Right

2 Left

3 Right, prosthesis in left hip

4 Left, prosthesis in right hip

1 Idiophatic coxarthrosis

2 Rheumatoid arthritis

3 Sequelae after hip fracture

4 Sequelae after dysplasia

5 Sequelae after dysplasia with dislocation

6 Sequelae after slipped capital femoral epiphysis

or Perthes disease

7 Ankylosing spondylitis

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

1 Loosening of acetabular component

2 Loosening of femoral component

3 Dislocation

4 Deep infection

5 Fracture of femur

6 Pain

7 Osteolysis in acetabulum

8 Osteolysis in proximal femur

9 Other:……………….……………………………

1 Change of femoral component

2 Change of acetabular component

3 Change of all components

4 Other:

- Removal of component (e.g. Girdlestone)

Which parts: ................................................

- Exchange of PE liner

- Exchange of caput

- Other: ............................................................

1 Anterior

2 Anterolateral

3 Lateral

4 Posterolateral

0 No 1 Yes

0 No

1 In acetabulum

2 In femur

3 Bone impaction in acetabulum

4 Bone impaction in femur (a.m. Ling/Gie)

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

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

Hydroxyapatite coated: 0 No 1 Yes

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

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

3 Uncemented

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

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

Hydroxyapatite coated: 0 No 1 Yes

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

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

3 Uncemented

1 Fixed caput

2 Modular system.

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

Catalogue number:.……………………….…..

Diameter (mm): .…..

0 No 1 Yes Name:……………………….…..

Dosage:.....................................................……

Duration (days): .....................................……..

1 ‘Green house’

2 With laminar air flow

3 Without laminar airflow

Skin to skin (min.):

0 No

1 Yes. Type:............................................…...........

Surgeon (who has filled in the form):

..............................................……….............

(Surgeon’s name is not registered)