If no, please proceed to QUESTION # 12 (page 4)
NormalNearly normalAbnormalSeverely abnormal
Non-traumatic; GRADUAL onsetNon-traumatic; SUDDEN onsetTraumatic; NON-CONTACT onsetTraumatic; CONTACT onset
NoYes
NoYes
MOON / MARS STUDY SURGEON FORM
Date of Surgery: / /
Operated Side:
Right
Left
Surgeon Initials:
Patient Initials:
If yes, which side? Right Left Both
Patient's Date of Birth: / /
M M D D Y E A R
Page 1
F M L Reconstruction Type:
Primary ACL (MOON Study)Revision ACL (MARS Study)Other: _________________
0 0 0 0 0
Medical Record #:
NoYes Lateral femoral condyle
Lateral tibial plateauOther
No
Yes
/ /0 4 0 1 0 7Rev.
1a. CONTRALATERAL KNEE (Surgeon asks the patient):
1b. MECHANISM OF INJURY (from the patient's perception):
2. INFLAMMATORY ARTHRITIS (ie. Rheumatoid):
3a. MRI taken? 3b. Does a bone bruise exist? 3c. If yes, in which compartment? (check all that apply)
4. PREVIOUS SURGERY (either knee):
0 0 0 0 0743
TYPE OF PREVIOUS SURGERY (Check ALL that apply)
R L MM Transplant R
R L MM Repair R
R L MM Debridement R
RightRight Left Medial5. MENISCUS SURGERY:
R L Posterolateral Corner Reconst
R L LCL Repair/Reconst
R L MCL Repair/Reconst
Right CollateralLeft
R L Intraarticular PCL ReconstR
R L PCL Repair
RRight Left PCL
R L Extraarticular ACL Reconst R
R L Intraarticular ACL Reconst R
R L ACL Repair R
Right Left ACL Right6. LIGAMENT SURGERY:
R
L LM Transplant
L LM Repair
L LM Debridement
Left Lateral
L Other OAU OAL
L Quad Tendon QAU QAL
L 2 Bundle Hamstring 2BAU 2BAL
L Single Hamstring R L
L PT Graft AU AL
Left Graft Type Auto Allo
L 4 Bundle Hamstring 4BAU 4BAL
proximalmedial
distallateral
anterior
Right Left
7. EXTENSOR MECHANISM SURGERY:
R L PT Repair
R L Quad Tendon Repair
R L Medial Imbrication Soft Tissue RealignmentR L Lateral Release
Tibial Tuberosity MovementLR
R L Trochleoplasty
R L Patellectomy
If Yes, check ALL that apply:
Page 2
0 0 0 0 0743
8. OSTEOARTHRITIS SURGERY:
R L Biopsy Synovium
R L Complete Synovectomy - Other: __________________________________
R L Partial Synovectomy - Other: _____________________________________
R L Complete Synovectomy - Inflam Arthritis RARA Other _____________OT
R L Partial Synovectomy - Inflam Arthritis RARA Other _____________OT
R L Excision - Other: ___________________
R L Excision - Lateral Plica
R L Excision - Medial Plica
Right Left
11. PLICA/ SYNOVIUM SURGERY:
9b. ARTICULAR SURFACE SURGERY:
Microfracture............................R L L LL L L L
R L OsteotomyR L Knee Replacement
Right Left Type Location: PAT TROCHMFC MTP LFC LTP
Right Left
Cell Therapy ............................R L L LL L L L
Mosaicplasty ...........................R L L LL L L L
Abrasion....................................R L L LL L L L
Drilling......................................R L L LL L L L
Shaving ....................................R L L LL L L L
Other (ie. infection) .................R LL LL L L L
NoneRightLeft
If yes, # of debridements:
Page 3
10. ARTHROSCOPIC AND/OR OPEN DEBRIDEMENTS FOR INFECTION:
9a. NUMBER OF PREVIOUS ARTICULAR CARTILAGE SURGERIES:
0 0 0 0 0743
RightLeft
NoYes
Tight Normal Lax
Obvious varus Normal Obvious valgus
Baja Normal Alta
Centered Subluxable Subluxed Dislocated
a. INVOLVED: None fluid wave (< 25cc) easily ballotable (25-60cc) tense knee (> 60cc)
16. EFFUSION:
b. Uninvolved: None fluid wave (< 25cc) easily ballotable (25-60cc) tense knee (> 60cc)
mild moderate severe
ActivePassivea. INVOLVED:
ActivePassive
Hyper Ext Flexion
(positive value)
Physical Exam Under Anesthesia
e.g. 10 degrees hyperextension, 150 degrees of flexion = 1 0 0 0 1 5 0
NoYes
15b. ROM:
(positive value)
Hyper Ext Flexion
Page 4
b. Uninvolved:
15a. ROM -- MEASURED WITH AN INSTRUMENTED GONIOMETER?
14a. GENERALIZED LAXITY:
b. Alignment:
c. Patellar position:
d. Patellar sublux/ dislocation:
13. SIDE OF INVOLVED KNEE:
12. Are the following PE findings recorded below from the OR as EUA?
0 0 0 0 0743
19. ENDPOINT LACHMAN:
Firm Soft
Firm Soft
(-1 to 2 mm) (3 to 5 mm) (6 to 10 mm) (>10 mm) (-1 to -3 mm) (< -3 mm)
17. LACHMAN (@ 25 deg. flexion): SIDE-TO-SIDE difference (involved minus uninvolved)
Normal degree laxity tight
NoYes
KTOther
.
20. TOTAL AP TRANSLATION (@ 70 deg. flexion): SIDE-TO-SIDE difference (involved minus uninvolved)
(0 to 2 mm) (3 to 5 mm) (6 to 10 mm) (> 10 mm)
mm
Physical Exam Under Anesthesia (cont'd)
15 lbs20 lbs30 lbs (recommended)max. manualOther: ____________ lbs
Page 5
C. FORCE USED:
B. SIDE-TO-SIDE EXCURSION:
18. INSTRUMENTED?
A. IF SO, BY WHAT TECHNIQUE?
a. INVOLVED:b. Uninvolved:
0 0 0 0 0743
b. Uninvolved
tibial plateau anterior to MFCtibial plateau flush with MFCtibial plateau behind the MFCtibial plateau significantly sagged behind MFC
21. POSTERIOR SAG (@ 70 deg. flexion):
a. INVOLVED
tibial plateau anterior to MFCtibial plateau flush with MFCtibial plateau behind the MFCtibial plateau significantly sagged behind MFC
(0 to 2 mm) (3 to 5 mm) (6 to 10 mm) (> 10 mm)
23. POSTERIOR DRAWER ENDPOINT:
Firm Soft
(0 to 2 mm) (3 to 5 mm) (6 to 10 mm) (> 10 mm)
24. MEDIAL JOINT OPENING (0 DEGREES): side-to-side difference (involved minus uninvolved)
25. MEDIAL JOINT OPENING (20 DEGREES): side-to-side difference (involved minus uninvolved)
(0 to 2 mm) (3 to 5 mm) (6 to 10 mm) (> 10 mm)
26. LATERAL JOINT OPENING (0 DEGREES): side-to-side difference (involved minus uninvolved)
27. LATERAL JOINT OPENING (20 DEGREES): side-to-side difference (involved minus uninvolved)
Firm Soft
(0 to 2 mm) (3 to 5 mm) (6 to 10 mm) (> 10 mm)
(0 to 2 mm) (3 to 5 mm) (6 to 10 mm) (> 10 mm)
22. POSTERIOR DRAWER TEST (@ 70 deg. flexion): Side-to-side difference with a posterior force applied from resting position (involved minus uninvolved):
Physical Exam Under Anesthesia (cont'd)
Page 6
a. INVOLVED:
b. Uninvolved:
0 0 0 0 0743
ProneSupine
b. Uninvolved: None Moderate Severe (palpable and audible)
b. Uninvolved: None Moderate Severe (palpable and audible)
b. Uninvolved: None Moderate Severe (palpable and audible)
b. Internal Rotation Test (90 deg. flexion)
GR 0 (< 5 deg.)GR 1 (6 to 10 deg.)GR 2 (11 to 19 deg.)GR 3 (> 20 deg.)
a. Internal Rotation Test (30 deg. flexion)
GR 0 (< 5 deg.)GR 1 (6 to 10 deg.)GR 2 (11 to 19 deg.)GR 3 (> 20 deg.)
b. External Rotation Test (90 deg. flexion)
GR 0 (< 5 deg.)GR 1 (6 to 10 deg.)GR 2 (11 to 19 deg.)GR 3 (> 20 deg.)
a. External Rotation Test (30 deg. flexion)
GR 0 (< 5 deg.)GR 1 (6 to 10 deg.)GR 2 (11 to 19 deg.)GR 3 (> 20 deg.)
28b. REVERSE PIVOT SHIFT:Negative GR 1 glide GR 2 clunk GR 3 grossNegative GR 1 glide GR 2 clunk GR 3 gross
28a. PIVOT SHIFT:Negative GR 1 glide GR 2 clunk GR 3 grossNegative GR 1 glide GR 2 clunk GR 3 gross
Performed in:
ProneSupine
30. POSTEROMEDIAL STRUCTURE(side-to-side comparison)
31. PATELLOFEMORAL CREPITUS (with full extension from 90 deg. of flexion)a. INVOLVED: None Moderate Severe (palpable and audible)
32. MEDIAL COMPARTMENT CREPITUS (with passive motion and VARUS force)a. INVOLVED: None Moderate Severe (palpable and audible)
33. LATERAL COMPARTMENT CREPITUS (with passive motion and VALGUS force)
a. INVOLVED: None Moderate Severe (palpable and audible)
29. POSTEROLATERAL STRUCTURE
Physical Exam Under Anesthesia (cont'd)
Page 7
(side-to-side comparison)
a. INVOLVED:b. Uninvolved:
a. INVOLVED:b. Uninvolved:
Performed in:
0 0 0 0 0743
VENDOR IMPLANT / ALLOGRAFT LABELS
Please affix all labels from implant/allograft devices used in the O.R. below:
Page 8
0 0 0 0 0743
LEFT KNEE ARTHROSCOPY DIAGRAM
COMMENTS:
LEFT KNEE ARTHROSCOPY DIAGRAM
COMMENTS:
Please use this figure to draw in patient's pathology and treatment :
Page 9
0 0 0 0 0743
RIGHT KNEE ARTHROSCOPY DIAGRAM
COMMENTS:
RIGHT KNEE ARTHROSCOPY DIAGRAM
COMMENTS:
Page 10
Please use this figure to draw in patient's pathology and treatment : 0 0 0 0 0
743
4. INFLAMMATORY SYNOVITIS:
NoneRheumatoid ArthritisTraumaticOther________
3. LOOSE BODIES:
NoYes, articular cartilageYes, boneYes, articular cartilage AND boneOther
2. TYPE OF OBJECTIVE DOCUMENTATION:
NoneVideoPicturesVideo AND pictures
1. TOURNIQUET TIME (in minutes):
5. SYNOVITIS TREATMENT:
NonePartial synovectomyComplete synovectomyBiopsy
INTRAOPERATIVE DATA
Page 11
0 0 0 0 0743
6. ACL TEAR (MOON STUDY ONLY):
No
Partial
Complete
A. Ligaments
8. PCL TEAR:
No
Partial
Complete
7. ACL GRAFT tear (MARS STUDY ONLY):
No
Partial
Complete
9. PCL GRAFT tear :
No
Partial
Complete
Page 12
if partial, the % of intact fibers:
if partial, the % of intact fibers:
if partial, the % of intact fibers:
if partial, the % of intact fibers:
0 0 0 0 0743
MCL TEAR identified via arthroscopy or arthrotomy
N/ANot localizedMen-tib ligMen-femTibialFemoralCombination = _____________________________
A. Ligaments (cont'd)
10. MCL:NormalGrade IGrade II (laxity at 20 degrees only)Grade III (laxity at 0 degrees)
11. LCL:NormalGrade IGrade II (laxity at 20 degrees only)Grade III (laxity at 0 degrees)
LATERAL COMPLEX TEAR identified via arthroscopy or arthrotomy
N/ANot localizedPartial LCLComplete LCLPopliteusPosterolateral cornerComplete LCL + posterolateral cornerLCL + posterolateral + popliteusOther ___________________________________
Arthrotomy
Arthroscopy
Page 13
0 0 0 0 0743
B. ACL Surgery
12. ACL RECONSTRUCTION: NoYes
- If NO, proceed to Section E (page 26)
NoRepair - midsubstanceRepair - avulsion of the femurRepair - avulsion of the tibiaRepair and augment
13. ACL REPAIR:
14. TYPE OF ACL RECONSTRUCTION:
PrimaryRevision
Page 14
High Tibial Osteotomy
Prior to today's surgeryAt today's surgery
Meniscus Transplant
Prior to today's surgeryAt today's surgery
Medial meniscus
Lateral meniscusPrior to today's surgeryAt today's surgery
Proceed to Section D (MARS Study only)
(Proceed to SECTION C -- MOON Study only)
0 0 0 0 0743
B-PT-BQuadriceps - boneHamstring - semitendinosisHamstring - semitendinosis + gracilisITBAchilles tendonTibialis anteriorTibialis posteriorOther: ___________________________
Arthroscopic assist, two-incisionArthroscopic assist, one-incision or endoscopicTraditional arthrotomy (patella retinaculum violated)Mini-arthrotomy (patella retinaculum intact)
NoSmall (< 5 mm)Moderate (> 5 mm but < 10 mm)Large (> 10 mm)
Bone tunnelOver-the-top (OTT)Modified OTT
18. PREVIOUS GRAFT HARVEST:Right Left
Right Left
Right Left
Autologous patellar tendon
Hamstring tendonQuadriceps tendon
17. # STRANDS (example, hamstring):
AutograftAllograftBoth allograft and autograftProsthetic
15. GRAFT TYPE:
16. GRAFT SOURCE:
19. SURGICAL EXPOSURE:
20. NOTCHPLASTY:
21. FEMORAL POSITION:
C. Primary ACLR (MOON Study only)
PLEASE DISREGARD SECTION C IF YOU ARE DOING A REVISION
Page 15
0 0 0 0 0743
C. Primary ACLR (MOON Study only)
"Freehand" / Placement with or without drill guideReference probe = ____________________Isometer type = ______________________X-RayReference probe + X-Ray
Interference screw (metal)Interference screw (bioabsorbable)Suture + button / EndobuttonSuture + postSuture + stapleStaple tissueScrew tissueInterference screw + suture to ___________________________Cross pin (bioabsorbable)Cross pin (nonabsorbable)Other: ____________________________
Bone tunnelOTTModified OTT
"Freehand"/ Placement with or without drill guideReference probe = __________________________Isometer type = ________________________X-RayReference probe + X-Ray
Interference screw (metal)Interference screw (bioabsorbable)Suture + buttonSuture + postSuture + stapleStaple tissueScrew tissueInterference screw + suture to __________________________Other: __________________________
PLEASE DISREGARD SECTION C IF YOU ARE DOING A REVISION
Page 16
23. FEMORAL FIXATION:
22. METHOD TO ACHIEVE FEMORAL POSITION:
24. TIBIAL POSITION:
25. METHOD TO ACHIEVE TIBIAL POSITION:
26. TIBIAL FIXATION:
0 0 0 0 0743
C. Primary ACLR (MOON Study only)
NoYes
--- Otherwise, please proceed to Section E (page 26) ---
PLEASE DISREGARD SECTION C IF YOU ARE DOING A REVISION
If a Collateral (MCL/LCL) or Corner (PM/PL) Surgery was performed, proceed to Questions 67 and 68 (page 24).
Page 17
27. ESTIMATED GRAFT EXCURSION, FROM 0-90 DEGREES:
29. POST-OP FULL ACTIVE OR PASSIVE ROM IS ALLOWED WHEN?
30. FWB WITHOUT SUPPORT IS ALLOWED WHEN?
31. HOW LONG DO YOU USE A FUNCTIONAL ACL STABILIZING BRACE FOR ACL POST-OP?
28. WAS AN EXTRAARTICULAR PROCEDURE PERFORMED?
mm
days
days post-op
days
0 0 0 0 0743
TraumaticTechnical error from prior surgeryBiologic failure to heal (ie. tissue stretching)Combination of aboveInfection (if YES, you are finished)Other
D. Revision ACLR (MARS STUDY)
32. WHAT REVISION NUMBER: One (first failure of ACL graft)TwoThreeFourFive
33. SURGEON'S OPINION ON CAUSE OF FAILURE:
34. IS SURGEON REVISION HIS/HER OWN FAILURE?NoYes
35. CAUSE OF TECHNICAL FAILURE (in Surgeon's opinion): (check all that apply)
36. PATIENT'S PRIOR INCISIONS: (check all that apply)
37. PRIOR SURGICAL TECHNIQUE: Arthroscopic two-incisionArthroscopic one-incisionTraditional arthrotomyMini-arthrotomy (patellar retinaculum intact)
HamstringBTB ipsilateral verticalBTB ipsilateral horizontalBTB contralateral verticalBTB contralateral horizontalAllograft tibial incision
NoneFemoral tunnel malpositionTibial tunnel malpositionMalalignment (in any plane)Femoral fixationTibial fixationAutograft sourceAllograft sourcePosteromedial laxityPosterolateral laxityOther _________________________
38. TECHNIQUE OF PRIOR ACL FEMORAL TUNNEL:Single tunnelDouble tunnel
/ / M M D D Y Y Y Y
Page 18
32a. DATE OF THE LAST ACL RECONSTRUCTION:
0 0 0 0 0743
39. VISUALIZATION OF FAILED ACLR GRAFT:ACL graft absentACL graft present, but elongatedACL graft present, but majority torn
40. PRIOR ACL GRAFT TYPE:
41. PRIOR GRAFT SOURCE:
44. CUTANEOUS NUMBNESS: AnteriorLateralMedialNone
Unknown
43. PREVIOUS GRAFT HARVEST:Autologous patellar tendon .......Hamstring tendon .....................Quadriceps tendon ...................
Involved Uninvolved kneeInvolved Uninvolved kneeInvolved Uninvolved knee
45. CURRENT SURGICAL EXPOSURE AND TECHNIQUE:
AutograftAllograftBoth autograft and allograftProstheticCombined (autograft or allograft with prosthetic)
BTBQuad BTHamstring - semitendinosisHamstring - semitendinosis + gracilisITBAchilles tendonTibialis anteriorTibialis posteriorUnknownOther: ___________________________
None
Arthroscopically assisted, one-incision; TRANS-TIBIAL drillingArthroscopically assisted, one-incision; anterior medial portal drillingArthroscopically assisted, two-incisionTraditional arthrotomy (patella retinaculum violated)Mini-arthrotomy (patella retinaculum intact) Page 19
42. NUMBER OF PRIOR HAMSTRING OR SOFT TISSUE STRANDS:
D. Revision ACLR (MARS STUDY) 0 0 0 0 0743
same tunnel aperture, optimum positionsame tunnel aperture, but compromised position (by how many mm _______)entirely new tunnel apertureblended new tunnel aperturedouble tunnel (add a 2nd tunnel)Over-the-top (OTT)modified OTT
46. CURRENT NOTCHPLASTY: NoSmall (< 5 mm)Moderate (> 5 mm but < 10 mm)Large (> 10 mm)
49b. CURRENT FEMORAL TUNNEL APERTURE POSITION (after drilling), IS BEST DESCRIBED AS:
47. PRIOR FEMORAL FIXATION:(check all that apply)
48. PRIOR FEMORAL TUNNEL APERTURE POSITION AT THE TIME OF REVISION:
DrillingDilation
49a. CURRENT FEMORAL TUNNEL METHOD:
Interference screw (metal)Interference screw (bioabsorbable)Stacked screwsSuture + button / EndobuttonSuture + postSuture + stapleStaple tissueScrew tissueInterference screw + suture to ___________________________Cross pin (bioabsorbable)Cross pin (nonabsorbable)Other: ____________________________
FEMORAL TUNNEL AND FIXATION DESCRIPTION
Ideal (both position and size of tunnel aperture)Ideal (both position and size), but enlarged tunnelsCompromised aperture position to VERTICALCompromised aperture postion to ANTERIORCompromised aperture size (ie. enlarged)Compromised - due to BOTH position and size of tunnel aperture
Page 20
D. Revision ACLR (MARS STUDY) 0 0 0 0 0743
52. CURRENT FEMORAL FIXATION: Interference screw (metal)Interference screw (bioabsorbable or composite)Stacked screwsSuture + button / EndobuttonSuture + postSuture + stapleStaple tissueScrew tissueInterference screw + suture to ___________________________Cross pin (bioabsorbable)Cross pin (nonabsorbable)Other: ____________________________
51. BONE QUALITY OF FEMUR: NormalAbnormal (ie. soft)
(check all that apply)
53. PRIOR TIBIAL FIXATION:(check all that apply)
Interference screw (metal)Interference screw (bioabsorbable)Stacked screwsSuture + button / EndobuttonSuture + postSuture + stapleStaple tissueScrew tissueInterference screw + suture to ___________________________Cross pin (bioabsorbable)Cross pin (nonabsorbable)Intrafix (bioabsorbable)Intrafix (metal)Other: ____________________________
TIBIAL TUNNEL AND FIXATION DESCRIPTION
Page 21
D. Revision ACLR (MARS STUDY)
Yes, at current procedureStaged (prior to current procedure)None
50. CURRENT FEMORAL TUNNEL BONE GRAFT:
0 0 0 0 0743
57. CURRENT TIBIAL TUNNEL BONE GRAFT:
56. CURRENT TIBIAL TUNNEL APERTURE (after drilling), IS BEST DESCRIBED AS:
Yes, at current procedureStaged (prior to current procedure)None
58. BONE QUALITY OF TIBIA: NormalAbnormal (ie. soft)
59. CURRENT TIBIAL FIXATION:(check all that apply)
54. PRIOR TIBIAL TUNNEL APERTURE POSITION AT THE TIME OF REVISION:
Interference screw (metal)Interference screw (bioabsorbable)Stacked screwsSuture + button / EndobuttonSuture + postSuture + stapleStaple tissueScrew tissueInterference screw + suture to ___________________________Cross pin (bioabsorbable)Cross pin (nonabsorbable)Intrafix (bioabsorbable)Intrafix (metal)Other: ____________________________
55. CURRENT TIBIAL TUNNEL METHOD: DrillingDilation
same tunnel aperture, optimum positionsame tunnel aperture, but compromised position (by how many mm _______)entirely new tunnel apertureblended new tunnel aperturedouble tunnel (add a 2nd tunnel)Over-the-top (OTT)modified OTT
Ideal (both position and size of tunnel aperture)Ideal (both position and size), but enlarged tunnel exists extraarticular within the plateauCompromised aperture position either to MEDIAL or LATERALCompromised aperture postion either to ANTERIOR or POSTERIORCompromised aperture size (ie. enlarged)Compromised - due to BOTH position and size of tunnel aperture
Page 22
D. Revision ACLR (MARS STUDY) 0 0 0 0 0743
60. CURRENT ACL GRAFT TYPE: AutograftAllograftBoth autograft and allograftProsthetic
61. CURRENT GRAFT SOURCE: BTBQuadriceps - BoneHamstring - semitendinosisHamstring - semitendinosis + gracilisITBAchilles tendonTibialis anteriorTibialis posteriorOther
63. BIOLOGIC ENHANCEMENT: NoYes (describe): __________________________
63a. LOCATION OF BIOLOGIC ENHANCEMENT: (check all that apply) None
Femoral tunnelIntra-articular graftTibial tunnel
62. DID YOU PRE-TENSION THE GRAFT? NoYes
Page 23
D. Revision ACLR (MARS STUDY)
61a. NUMBER OF HAMSTRING OR SOFT TISSUE STRANDS:
64. ESTIMATED GRAFT EXCURSION (at full ROM; 0-135 degrees): mm
65. KNEE POSITION AT TIME OF GRAFT FIXATION (in degrees):
(Extension) Positive #(Hyper-extension)66. TENSION ON GRAFT AT TIME OF FIXATION:
ManualMeasured, by:_________________________
0 0 0 0 0743
67. MCL OR POSTEROMEDIAL REPAIR OR RECONSTRUCTION PERFORMED?
NoYes
- If NO, proceed to question # 68
NoYes
- If NO, proceed to question #69
Collateral (MCL/LCL) and Corner (PM, PL) Structures
Repair sutureRepair staple/screwRepair suture + repair staple/screwAutograft reconstruction = __________________________Allograft reconstruction = ___________________________Other: ________________________________
Repair sutureRepair staple/screwRepair suture + repair staple/screwAutograft reconstruction = __________________________Allograft reconstruction = ___________________________Other: ________________________________
Page 24
D. Revision ACLR (MARS STUDY)
68. LCL OR POSTEROLATERAL REPAIR OR RECONSTRUCTION PERFORMED?
67a. Type of MCL or PM Surgery:
68a. Type of LCL or PL Surgery:
0 0 0 0 0743
72. DO YOU PRESCRIBE A MOTION CONTROL BRACE (double upright or knee immobilizer) POST-OP?
NoYes
NoYes
NoYes
NoYes
NoYes
days
REHABILITATION
69a. If yes, when do you allow full passive ROM?
NoYes
Page 25
D. Revision ACLR (MARS STUDY)
69. DO YOU RESTRICT PASSIVE ROM POST-OP?
days post-op
70. DO YOU RESTRICT ACTIVE ROM POST-OP?
70a. If yes, when do you allow full active ROM? days post-op
71a. If yes, when do you allow full weightbearing w/o support?
days post-op
71. DO YOU RESTRICT FULL WEIGHT-BEARING W/O SUPPORT (ie. crutches) POST-OP?
72a. If yes, how long do you prescribe a motion control brace to be used for?
73. WILL AN ACL DEROTATION BRACE BE USED IN POST-OP REHAB?
73a. If so, for how long? days
74a. If so, for how long? days
74. WILL AN ACL DEROTATION BRACE BE USED IN RETURN TO SPORT?
0 0 0 0 0743
If NO tear, proceed to Section F (page 29)
E. Medial Meniscus Tear #1
AnteriorPosteriorAnterior + posterior
Central 1/3Middle 1/3Peripheral 1/3Central + middle 1/3Central + middle + peripheral 1/3Middle + peripheral 1/3
76. LOCATION:
NoYes
77. TYPE:
Yes, partialYes, complete
RadialObliqueLongitudinal - verticalBucket handle - displacedHorizontalComplex
.
Yes
Yes
(proceed to question #85)
(proceed to question #75b)
Page 26
78. LENGTH (in mm):
75b. MEDIAL MENISCUS TEAR #1:
a. Anterior vs. Posterior
b. Central vs. Peripheral
79. DEGENERATIVE COMPONENT (cavitation, multiple cleavage planes, etc.):
75a. DOES THIS PATIENT HAVE A MEDIAL MENISCUS TEAR?
DID THIS PATIENT HAVE PRIOR MENISCUS SURGERY?OR
0 0 0 0 0743
81. Quantify extent of CURRENT EXCISION:
None33% (central 1/3)67% (central + middle 1/3)100% (entire meniscus)
None33%67%100%
NormalDegenerative changesStable tearUnstable tearTear left in-situ
IntactDisrupted
No treatment for tearExcisionRepairAbrade + trephineMeniscus transplant
80. TREATMENT:
E. Medial Meniscus Tear #1 (cont'd)
Page 27
a. Posterior
b. Anterior
c. Remaining meniscus tissue
d. Circumferential hoop fibers
Please document on knee diagram on pages 9/10 of this survey(If greater than or equal to 50% of a region is excised, then compartment is considered excised)
0 0 0 0 0743
E. Medial Meniscus Tear #1 (cont'd)
Inside-outOutside-inAll-inBoth inside-out and all-inOther
Absorbable sutureNonabsorbable sutureAbsorbable stint or implant - name ______________________
85. WAS PREVIOUS MENISCUS SURGERY PERFORMED?
NoYes, excisionYes, repair healed/stableYes, repair not healed, unstable
86. Quantify extent of PREVIOUS Meniscus Surgery (based on surgeon's evaluation at ACLR)
None33% (central 1/3)67% (central + middle 1/3)100% (entire meniscus)
None33%67%100%
For Additional Medial Meniscal Pathology, also complete Section L (page 39)
Page 28
83. TYPE OF "SUTURE":
82. CURRENT MENISCUS REPAIR TECHNIQUE:
a. Posterior
84. NUMBER OF "SUTURES":
if any implant, please check next box.
b. Anterior
Please document on knee diagram on pages 9/10 of this survey(If greater than or equal to 50% of a region is excised, then compartment is considered excised)
0 0 0 0 0743
F. Lateral Meniscus Tear #1
AnteriorPosteriorAnterior + posterior
Central 1/3Middle 1/3Peripheral 1/3Central + middle 1/3Central + middle + peripheral 1/3Middle + peripheral 1/3
88. LOCATION:
If NO tear, proceed to Section G (page 32)
Yes, partialYes, complete
89. IS THE TEAR CENTRAL OR ADJACENT TO THE POPLITEAL HIATUS?
NoYes
90. TYPE:
.
NoYes
92. DEGENERATIVE COMPONENT (cavitation, multiple cleavage planes, etc.):
RadialObliqueLongitudinal (vertical)Bucket handle (displaced)HorizontalComplex
Yes (proceed to question #87b)
Yes (proceed to question #98)
Page 29
a. Anterior vs. Posterior
b. Central vs. Peripheral
91. LENGTH (in mm):
87b. LATERAL MENISCUS TEAR #1:
87a. DOES THIS PATIENT HAVE A LATERAL MENISCUS TEAR?
DID THIS PATIENT HAVE PRIOR MENISCUS SURGERY?OR
0 0 0 0 0743
IntactDisrupted
NormalDegenerative changesStable tearUnstable tearTear left in-situ
None33%67%100%
None33% (central 1/3)67% (central + middle 1/3)100% (entire meniscus)
94. Quantify extent of CURRENT EXCISION:
93. TREATMENT: No treatment for tearExcisionRepairAbrade + trephineMeniscus transplant
F. Lateral Meniscus Tear #1 (cont'd)
Page 30
Please document on knee diagram on pages 9/10 of this survey(If greater than or equal to 50% of a region is excised, then compartment is considered excised)
a. Posterior
b. Anterior
c. Remaining meniscus tissue
d. Circumferential hoop fibers
0 0 0 0 0743
Inside-outOutside-inAll-inBoth inside-out and all-inOther
Absorbable sutureNonabsorbable sutureAbsorbable stint or implant - name ______________________
NoYes, excisionYes, repair healed/stableYes, repair not healed, unstable
None33%67%100%
None33% (central 1/3)67% (central + middle 1/3)100% (entire meniscus)
F. Lateral Meniscus Tear #1 (cont'd)
For Additional Lateral Meniscal Pathology, also complete Section M (page 41)
Page 31
95. CURRENT MENISCUS REPAIR TECHNIQUE:
99. Quantify extent of PREVIOUS Meniscus Surgery (based on surgeon's evaluation at ACLR)Please document on knee diagram on pages 9/10 of this survey(If greater than or equal to 50% of a region is excised, then compartment is considered excised)
a. Posterior
b. Anterior
98. WAS PREVIOUS MENISCUS SURGERY PERFORMED?
97. NUMBER OF "SUTURES":
96. TYPE OF "SUTURE":if any implant, please check next box.
0 0 0 0 0743
G. Femoral Condyle Articular Lesions
0 degrees45 degrees90 degrees
100. Grade lesion of each section (by WORST GRADE) involved via I-IV Outerbridge scale using "1,2,3,4"
where, 1 = Grade I (normal) 2 = Grade II (fissures, superficial changes) 3 = Grade III (fragmentation, deep changes) 4 = Grade IV (bone)
(please refer to knee diagram above and on pages 9/10 of this survey)
0 degrees45 degrees90 degrees
Page 32
101a. MEDIAL FEMORAL CONDYLE: 101b. LATERAL FEMORAL CONDYLE:
Where is the lesion weight-bearing?
RIGHT LEFTFemoralCondyles
0 deg45 deg90 deg
0 deg45 deg90 deg
0 0 0 0 0743
106. DIMENSIONS OF LARGEST LESION:
G. LFC -- Articular Lesions
NoYes
NoYes
103. CHONDROMALACIA:
Grade IGrade II fissures (superficial changes)Grade III fragmentation (deep changes)Grade IV (bone)
0%25%50%75%100%
NoneChondroplasty (debride loose art. cartilage only)Abrasion arthroplasty (debride into bone)MicrofractureMosaicplastyCell RxAllograftThermalOther: __________________________
Sagittal (A to P)Coronal (M to L)
b. Degenerative
Yes
If NO, proceed to Next Page (MFC - Articular Lesions)
NoYes
NoneChondroplastyAbrasion arthroplastyMicrofractureMosaicplastyCell RxAllograftThermalOther: __________________________
Page 33
102. IS AN ARTICULAR LESION PRESENT ON THE LATERAL FEMORAL CONDYLE?
a. Acute (Traumatic) c. Grade
111. TREATMENT FOR THESE ARTICULAR CARTILAGE FRACTURES:
110. ORIENTATION OF LONGEST/DEEPEST FRACTURE:
109. LENGTH OF THE LONGEST/DEEPEST FRACTURE:
mm
#0 - 9 (maximum)108b. NUMBER OF FRACTURES:
108. ARTICULAR CARTILAGE FRACTURES? (linear cracks)
107. TREATMENT FOR CHONDROMALACIA:
105. DEGREES ON CONDYLE SURFACE: (from anterior to posterior)
104. % OF MEDIAL-TO-LATERAL WIDTH:
Length:
Width: mm
mm
degrees
0 0 0 0 0743
G. MFC -- Articular Lesions
Yes
113. CHONDROMALACIA:
NoYes
NoYes
Grade IGrade II fissures (superficial changes)Grade III fragmentation (deep changes)Grade IV (bone)
0%25%50%75%100%
NoneChondroplasty (debride loose art. cartilage only)Abrasion arthroplasty (debride into bone)MicrofractureMosaicplastyCell RxAllograftThermalOther: __________________________
NoYes
NoneChondroplastyAbrasion arthroplastyMicrofractureMosaicplastyCell RxAllograftThermalOther: __________________________
Sagittal (A to P)Coronal (M to L)
Page 34
121. TREATMENT FOR THESE ARTICULAR CARTILAGE FRACTURES:
120. ORIENTATION OF LONGEST/DEEPEST FRACTURE:
119. LENGTH OF THE LONGEST/DEEPEST FRACTURE:
mm
117. TREATMENT FOR CHONDROMALACIA:
116. DIMENSIONS OF LARGEST LESION:
Length:
Width: mm
mm
115. DEGREES ON CONDYLE SURFACE: (from anterior to posterior)
degrees
114. % OF MEDIAL-TO-LATERAL WIDTH:
a. Acute (Traumatic) b. Degenerative c. Grade
112. IS AN ARTICULAR LESION PRESENT ON THE MEDIAL FEMORAL CONDYLE?
118. ARTICULAR CARTILAGE FRACTURES? (linear cracks)
118b. NUMBER OF FRACTURES:
#0 - 9 (maximum)
If NO, proceed to Next Page (MFC - Articular Lesions) If NO, proceed to Next Page (LTP - Articular Lesions)
0 0 0 0 0743
128. LENGTH OF THE LONGEST/DEEPEST FRACTURE:
H. LTP -- Articular Lesions
NoYes
NoYes
Grade IGrade II fissures (superficial changes)Grade III fragmentation (deep changes)Grade IV (bone)
0%25%50%75%100%
NoneChondroplasty (debride loose art. cart. only)Abrasion arthroplasty (debride into bone)MicrofractureMosaicplastyCell RxAllograftThermalOther: __________________________
123. CHONDROMALACIA:
Yes
0%25%50%75%100%
NoYes
NoneChondroplastyAbrasion arthroplastyMicrofractureMosaicplastyCell RxAllograftThermalOther: __________________________
Sagittal (A to P)Coronal (M to L)Outline of inner meniscus contourOther: _______________________
Page 35
122. IS AN ARTICULAR LESION PRESENT ON THE LATERAL TIBIAL PLATEAU?
a. Acute (Traumatic) b. Degenerative c. Grade
130. TREATMENT FOR THE ARTICULAR CARTILAGE FRACTURES:
129. ORIENTATION OF LONGEST/DEEPEST FRACTURE:
126. TREATMENT FOR CHONDROMALACIA:
mm
127b. NUMBER OF FRACTURES:#0 - 9 (maximum)
124. % OF MEDIAL-TO-LATERAL WIDTH:
125. % OF ANTERIOR-TO-POSTERIOR:
127. ARTICULAR CARTILAGE FRACTURES? (linear cracks)
If NO, proceed to Next Page (MFC - Articular Lesions) If NO, proceed to Next Page (MTP - Articular Lesions)
0 0 0 0 0743
I. MTP -- Articular Lesions
Yes
132. CHONDROMALACIA:
NoYes
NoYes
Grade IGrade II fissures (superficial changes)Grade III fragmentation (deep changes)Grade IV (bone)
0%25%50%75%100%
NoneChondroplasty (debride loose art cart only)Abrasion arthroplasty (debride into bone)MicrofractureMosaicplastyCell RxAllograftThermalOther: __________________________
0%25%50%75%100%
NoYes
NoneChondroplastyAbrasion arthroplastyMicrofractureMosaicplastyCell RxAllograftThermalOther: __________________________
Sagittal (A to P)Coronal (M to L)Outline of inner meniscus contourOther: _______________________
Page 36
131. IS AN ARTICULAR LESION PRESENT ON THE MEDIAL TIBIAL PLATEAU?
a. Acute (Traumatic) b. Degenerative c. Grade
139. TREATMENT FOR THESE ARTICULAR CARTILAGE FRACTURES:
138. ORIENTATION OF LONGEST/DEEPEST FRACTURE:
133. % OF MEDIAL-TO-LATERAL WIDTH:
134. % OF ANTERIOR-TO-POSTERIOR:
136. ARTICULAR CARTILAGE FRACTURES? (linear cracks)
136b. NUMBER OF FRACTURES:
#0 - 9 (maximum)
137. LENGTH OF THE LONGEST/DEEPEST FRACTURE:
mm
135. TREATMENT FOR CHONDROMALACIA:
If NO, proceed to Next Page (MFC - Articular Lesions) If NO, proceed to Next Page (Patellar - Articular Lesions)
0 0 0 0 0743
J. PATELLAR -- Articular Lesions
Yes
141. CHONDROMALACIA:
NoYes
NoYes
Grade IGrade II fissures (superficial changes)Grade III fragmentation (deep changes)Grade IV (bone)
NoneChondroplasty (debride loose articular cartilage only)Abrasion arthroplasty (debride into bone)MicrofractureMosaicplastyCell RxAllograftThermalOther: __________________________
NoYes
144. WORST Grade Chondromalacia of each section involved via I-IV scale using "1,2,3,4"
IGHT EFT
Page 37
143. ARTICULAR CARTILAGE FRACTURES? (linear cracks)
142. TREATMENT FOR CHONDROMALACIA:
a. Acute (Traumatic) b. Degenerative c. Grade
140. IS AN ARTICULAR LESION PRESENT ON THE PATELLA?
If NO, proceed to Next Page (MFC - Articular Lesions) If NO, proceed to Next Page (Trochlear - Articular Lesions)
0 0 0 0 0743
K. TROCHLEAR -- Articular Lesions
NoneChondroplasty (debride loose articular cartilage only)Abrasion arthroplasty (debride into bone)MicrofractureMosaicplastyCell RxAllograftThermalOther: __________________________
Yes
146. CHONDROMALACIA:
NoYes
NoYes
Grade IGrade II fissures (superficial changes)Grade III fragmentation (deep changes)Grade IV (bone)
NoYes
RIGHT LEFT
149. WORST Grade Chondromalacia of each section involved via Outerbridge scale using "1,2,3,4"
TrochlearRegion
Page 38
148. ARTICULAR CARTILAGE FRACTURES? (linear cracks)
147. TREATMENT FOR CHONDROMALACIA:
a. Acute (Traumatic) b. Degenerative c. Grade
145. IS AN ARTICULAR LESION PRESENT ON THE TROCHLEAR REGION?
If NO, proceed to Next Page (Section L)
0 0 0 0 0743
L. Medial Meniscus Tear #2
Central 1/3Middle 1/3Peripheral 1/3Central + middle 1/3Central + middle + peripheral 1/3Middle + peripheral 1/3
AnteriorPosteriorAnterior + posterior
151. LOCATION:
Yes, partialYes, complete
If NO tear, proceed to Section M (page 41)
NoYes
No treatment for tearExcisionRepairAbrade + trephineMeniscus transplant
155. TREATMENT:
RadialObliqueLongitudinal (vertical)Bucket handle (displaced)HorizontalComplex
.
Yes
Page 39
154. DEGENERATIVE COMPONENT (cavitation, multiple cleavage planes, etc.):
153. LENGTH (in mm):
152. TYPE:
b. Central vs. Peripheral
a. Anterior vs. Posterior
150b. MEDIAL MENISCUS TEAR #2:
150a. DOES THIS PATIENT HAVE A 2ND MEDIAL MENISCUS TEAR?
0 0 0 0 0743
NoneInside-outOutside-in
All-inBoth inside-out and all-inOther
NoneAbsorbable sutureNonabsorbable sutureAbsorbable stint or implant - name _____________________________
160. WAS PREVIOUS MENISCUS SURGERY PERFORMED?NoYes, excisionYes, repair healed/stableYes, repair not healed, unstable
156. Quantify extent of CURRENT EXCISION:
None33% (central 1/3)67% (central + middle 1/3)100% (entire meniscus)
None33%67%100%
IntactDisrupted
NormalDegenerative changesStable tearUnstable tearTear left in-situ
L. Medial Meniscus Tear #2 (cont'd)
Page 40
(If greater than or equal to 50% of a region is excised, then compartment is considered excised)
a. Posterior
b. Anterior
c. Remaining meniscus tissue
d. Circumferential hoop fibers
157. CURRENT MENISCUS REPAIR TECHNIQUE:
158. TYPE OF "SUTURE":
159. NUMBER OF "SUTURES":
if any implant, please check next box.
0 0 0 0 0743
M. Lateral Meniscus Tear #2
AnteriorPosteriorAnterior + posterior
Central 1/3Middle 1/3Peripheral 1/3Central + middle 1/3Central + middle + peripheral 1/3Middle + peripheral 1/3
If NO tear, proceed to Section N (page 43)
Yes, partialYes, complete
NoYes
.
NoYes
164. TYPE: RadialObliqueLongitudinal (vertical)Bucket handle (displaced)HorizontalComplex
Yes
Page 41
161a. DOES THIS PATIENT HAVE A 2ND LATERAL MENISCUS TEAR?
161b. LATERAL MENISCUS TEAR #2:
162. LOCATION:
a. Anterior vs. Posterior
b. Central vs. Peripheral
163. IS THE TEAR CENTRAL OR ADJACENT TO THE POPLITEAL HIATUS?
165. LENGTH (in mm):
166. DEGENERATIVE COMPONENT (cavitation, multiple cleavage planes, etc.):
mm
No treatment for tearExcisionRepairAbrade + trephineMeniscus transplant
167. TREATMENT:
0 0 0 0 0743
NoYes, excisionYes, repair healed/stableYes, repair not healed, unstable
Inside-outOutside-in
All-inBoth inside-out and all-inOther
NoneAbsorbable sutureNonabsorbable sutureAbsorbable stint or implant - name _____________________________
Quantify extent of CURRENT EXCISION:
None33% (central 1/3)67% (central + middle 1/3)100% (entire meniscus)
None33%67%100%
NormalDegenerative changesStable tearUnstable tearTear left in-situ
IntactDisrupted
M. Lateral Meniscus Tear #2 (cont'd)
Page 42
(If greater than or equal to 50% of a region is excised, then compartment is considered excised)
a. Posterior
b. Anterior
c. Remaining meniscus tissue
d. Circumferential hoop fibers
168. CURRENT MENISCUS REPAIR TECHNIQUE:
169. TYPE OF "SUTURE":
170. NUMBER OF "SUTURES":
171. WAS PREVIOUS MENISCUS SURGERY PERFORMED?
0 0 0 0 0743
N. PCL Repair or Reconstruction Performed?
AutograftAllograftBoth allograft and autograftProsthetic
Arthroscopic - assisted (outside-in)Arthroscopic (endoscopic, all inside)Traditional arthrotomy (patella everted)Miniarthrotomy (patella not everted)
Single bone tunnel (anterolateral)Double bone tunnel (anterolateral and posteromedial)
ReconstructionRepair mid-substanceRepair avulsion femurRepair avulsion tibiaAugment/Primary repair
PrimaryRevision
175. GRAFT SOURCE:
BPTBQuad TBHamstringAchilles TBOther: _____________________
BPTB/HamstringQuad TB/HamstringAchilles Split TBBPTB/BPTBOther: ______________________
NoYes
- If NO, proceed to Section O
"Freehand" / Placement with or without drill guideReference probe _______________XrayRef probe + xrayOther _______________
Page 43
178. METHOD USED TO ACHIEVE FEMORAL POSITION:
177. FEMORAL POSITION:
176. SURGICAL EXPOSURE (Femoral):
Single Bundle Double Bundle
174. GRAFT TYPE:
173. PRIMARY (1st) OR REVISION:
172. PCL REPAIR OF RECONSTRUCTION PERFORMED?
0 0 0 0 0743
183. Graft tensioned at degrees flexion
"Freehand"/Placement with or without drill guideReference probe _______________XrayFreehand with or without drill guide + xrayRef probe + xrayOther _______________
N. PCL Repair or Reconstruction Performed (cont'd)
Interference screw (metal)Interference screw (bioabsorbable)Suture + buttonSuture + postSuture + stapleStaple tissue
Screw tissueInterference screw + suture to _______________Interference screw + stapleOther: ___________________
Bone tunnelPosterior tibial inlayOther __________________
Screw and washer 6.5 mm cancellous screwScrew and washer 4.0 mm malleolar screwScrew and washer small fragment screwsInterference screw (metal)Interference screw (bioabsorbable)Suture + buttonSuture + post
Suture + stapleStaple tissueScrew tissueInterference screw + suture to ________Interference screw + stapleOther: ________________________
Page 44
180. TIBIAL POSITION:
179. FEMORAL FIXATION:
181. METHOD USED TO ACHIEVE TIBIAL POSITION:
182. TIBIAL FIXATION:
184. Residual posterior laxity following graft fixation at 70 degrees flexion: mm
185. Postop full active or passive ROM is allowed when? days
186. FWB without support is allowed when? days post-op
189. When do you allow open chain activities? days
days188. When do you allow closed chain activities?
187. How long do you use a functional PCL stabilizing brace for ADL post-op? days
0 0 0 0 0743
NoYes
ArthroscopicMini-arthrotomyComplete Arthrotomy (evert patella)Extra-articular MEDIALExtra-articular LATERALPercutaneous MEDIALPercutaneous LATERAL
MEDIAL ARTICULAR CARTILAGE FINDINGS
YesNo
medial to lateral width (%)
medial to lateral (in mm)
anterior to posterior (in degrees)
anterior to posterior (in mm)
intactcracked attachedcracked detached lying in-situcracked detached loose body - if attached, % of lesion still intact
LATERAL ARTICULAR CARTILAGE FINDINGS
YesNo
medial to lateral width (%)
medial to lateral (in mm)
anterior to posterior (in degrees)
anterior to posterior (in mm)
OCD LESION: Yes No
- If NO, go to #193
- If NO, go to #194
intactcracked attachedcracked detached lying in-situcracked detached loose body
- if attached, % of lesion still intact
TROCHLEAR ARTICULAR CARTILAGE FINDINGS
YesNo - If NO, go to #195
medial to lateral width (%)
medial to lateral (in mm)
anterior to posterior (in degrees)
anterior to posterior (in mm)intactcracked attachedcracked detached lying in-situcracked detached loose body
- if attached, % of lesion still intact
O. OCD LESION
Page 45
190. PROCEDURE FOR OSTEOCHONDRITIS DISSECANS?
191. SURGICAL EXPOSURE (check all that apply):
192. MEDIAL FEMORAL CONDYLE OCD?
193. LATERAL FEMORAL CONDYLE OCD?
194. TROCHLEA OCD?
(if so, you are finished with this form)
0 0 0 0 0743
YesNo
TREATMENT
articular cartilage onlypartial excision cartilage and bonecomplete excisionother
YesNo
If excision, check any additional procedures that apply:
debridementdrillingmicrofractureabrasion arthroplastybone graftingosteochondral autograft transplantosteochondral allograft transplantautologous chondrocyte implantation
TREATMENT OF FRAGMENTS NOT EXCISED
antegraderetrograde
(proximal to distal)(through articular cartilage)
YesNo
O. OCD LESION
If yes,
Page 46
195. DEBRIDEMENT:
196. EXCISION OF LOOSE BODY:
197. DRILLING:
a. # of cartilage punctures:
b. total # of drill passes (multi-directional same cartilage puncture):
c. mm K-wire size:
0 0 0 0 0743
YesNo
AO type screw
Bioabsorbable screw
Herbert - Whipple
YesNo
Accufix
Pins metal threaded
Pins metal smooth
Pins bioabsorbable
Biologic fixation - matchstick bone plugs
Biologic fixation - osteochondral autograft
O. OCD LESION
Page 47
199. FIXATION:
3. Cannulated:1. Size (mm):
2. # of screws:
1. Size (mm):
2. # of screws:
1. Size (mm):
2. # of screws:
1. Size (mm):
2. # of screws:
1. Size (mm):
2. # of screws:
1. Size (mm):
2. # of screws:
1. Size (mm):
2. # of screws:
1. Size (mm):
2. # of screws:
1. Size (mm):
2. # of screws:
3. Antegrade:
4. Retrograde:
3. Antegrade:
4. Retrograde:
3. Antegrade:
4. Retrograde:
0 0 0 0 0743
YesNo
AntegradeRetrograde packed behind fragment
AutograftAllograftOther supplementation
Medial femoral condyleLateral femoral condyleProximal tibiaIliac crest
- If NO, you are finished with this form
O. OCD LESION
Page 48
199. BONE GRAFTING:
200. BONE GRAFTING TECHNIQUE:
201. BONE GRAFT SOURCE:
source --
0 0 0 0 0743
END OF FORM.
THANK YOU!
0 0 0 0 0743
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