tcjrc023s
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1.
What Is the PRINCIPAL Reason for Revision (Choose ONLY ONE)?
(Required.)
Dislocation/Instability
Infection
Periprosthetic fracture
Aseptic Loosening
Mechanical failure: Implant fracture
Polywear
Subsidence
Osteolysis
Adverse Local Tissue Reaction (ALTR)
Metallosis
Implant Recall
Heterotopic Ossification
Other (please specify)
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2.
What are the SECONDARY Reason(s) for Revision (Choose ALL that apply)?
(Required.)
None
Dislocation/Instability
Infection
Periprosthetic fracture
Aseptic Loosening
Mechanical failure: Implant fracture
Polywear
Subsidence
Osteolysis
Adverse Local Tissue Reaction (ALTR)
Metallosis
Implant Recall
Heterotopic Ossification
Other (please specify)
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3.
Where is the location of the loosening?
(Required.)
Cement from bone interface
Cement from implant interface
Bone from implant interface
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4.
Was there associated polyethylene wear?
(Required.)
Yes
No
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5.
Was there Soft Tissue Insufficiency?
(Required.)
Yes
No
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6.
Was there Abductor Insufficiency?
(Required.)
Yes
No
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7.
Was there Capsular Insufficiency?
(Required.)
Yes
No
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8.
What was the INDEX bearing combination?
(Required.)
MoP
MoM
CoP
CoC
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9.
Did the PREVIOUS femoral head have a skirt/collar?
(Required.)
Yes
No
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10.
What is the location of Osteolysis?
(Required.)
Femoral
Acetabular
Both
None
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11.
Is there presence of Metallosis / Metalic Debris?
(Required.)
Yes
No
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12.
Is there presence of Pseudotumor?
(Required.)
Yes
No
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13.
Is there trunnion corosion?
(Required.)
Yes
No
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14.
What is the intraoperative tissue assessment?
(Required.)
Normal Tissue
1 - Fluid collection (mild synovial reaction, capsular dehiscence)
2 - the same as 1, but with moderate synovial reaction
3 -the same as 2, but with damage to the abductor muscle or associated soft tissue
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15.
Please indicate the Special Techniques performed on the Acetabulum (Choose ALL that apply)
(Required.)
None
Acetabular Impaction Grafting
Femoral Bone Grafting (Acetabular Revision Only)
Morcelized allograft
Morcelized autograft
Metallic augments
Structural allograft
Structural autograft
DBX (Demineralized bone matrix)
Other (please specify)
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16.
Please indicate the Special Techniques performed on the Femur (Choose ALL that apply)
(Required.)
None
Femoral Impaction Grafting
Extended Trochanteric Osteotomy
Wagner Spherical Osteotomy
Other (please specify)
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17.
What was the ACETABULAR BONE LOSS CLASSIFICATION (Paprosky Class)?
(Required.)
N/A
Type I
Type IIA
Type IIB
Type IIC
Type IIIA
Type IIIB
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18.
What type of skin closure was used (Choose ALL that apply)?
(Required.)
Suture(s)
Subcuticular
Staples
Antibiotics impregnated
Locking sutures
Local Fasciocultaneous Flap
Gastrocnemius Flap
Gluteus Maximus Flap
Perforator Flap
Vastus Lateralis Flap
Other Flap (please specify)
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19.
What was the dressing used?
(Required.)
Non-occlusive (e.g. gauze/bandage)
Occlusive/Adhesive (e.g. AquaCel, Mepilex)
Vacuum Assisted (e.g. Prevena/VAC)