Surgical Case Study Form

Disclaimer:
You are about to submit a patient case study. Your feedback is important to us and may be shared publicly to highlight customer experiences, testimonials, and other promotional content.

By submitting this form, you acknowledge and agree that your response may be used in future marketing and distribution by Fusion Orthopedics USA, LLC. Additionally, you confirm that you have obtained prior written consent from all individuals, including the patient, referenced in the study. We value your privacy and will ensure that any personal information is handled in accordance with our privacy policy. If you have any concerns or wish to reject consent for your response to be used in marketing material, please do not proceed with submission of this form.

HIPAA Consent Form*

Must be signed by patient

HIPAA Compliance Form can be downloaded here.

Your Name*

First NameLast Name

Your Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Your Email*

example@example.com

Injury/Deformity Treated*

Please enter the specific injury or deformity that was addressed during the procedure. Examples include "Bunion Correction," "Hammertoe Correction," or "Distal Fibula Fracture." Be as precise as possible to ensure clarity and accuracy in the case study documentation.

Case Summary*

Provide a brief summary of the entire surgery, including an overview of how the procedure went from the surgeon's perspective. Highlight the key steps, the success of the operation, and any notable outcomes. Additionally, discuss how Fusion Orthopedics products and instruments used during the surgery contributed to the overall success and efficiency of the procedure.

Pre-Op: Image(s)*

Please upload the pre-operative X-ray images for the patient. These images should clearly show the areas of interest related to the procedure. Ensure that the images are high quality and include multiple views if necessary to provide a comprehensive understanding of the patient's condition prior to the operation.

Pre-Op: Image Description(s)*

Please provide a detailed description of the patient and the procedure performed. Include relevant information such as the patient's diagnosis, treatment plan, and any specific techniques or equipment used during the procedure. Additionally, please provide a description of the pre-op x-ray images uploaded above.

Case Overview Part 1: Image(s)*

Please upload images related to the 1st part of the surgical technique. Ensure the images clearly depict the actions, instruments, and techniques used in this initial phase of the procedure.

Case Overview Part 1: Image Description(s)*

Detail the 1st part of the surgical case. Include specific actions, instruments, and techniques used. Please reference images associated with the specific surgical case to provide a clear understanding of this part.

Would You Like to Add a 2nd Part to the Case Overview?*

NoYes

Case Overview Part 2: Image(s)*

Please upload images for the 2nd part of the surgical technique. The images should clearly illustrate the actions performed, instruments utilized, and techniques applied during this phase.

Case Overview Part 2: Image Description(s)*

Detail the 2nd part of the surgical case. Include specific actions, instruments, and techniques used. Please reference images associated with the specific surgical case to provide a clear understanding of this part.

Would You Like to Add a 3rd Part to the Case Overview?*

NoYes

Case Overview Part 3: Image(s)*

Please upload images for the 3rd part of the surgical technique. The images should clearly illustrate the actions performed, instruments utilized, and techniques applied during this phase.

Case Overview Part 3: Image Description(s)*

Detail the 3rd part of the surgical case. Include specific actions, instruments, and techniques used. Please reference images associated with the specific surgical case to provide a clear understanding of this part.

Would You Like to Add a 4th Part to the Case Overview?*

NoYes

Case Overview Part 4: Image(s)*

Please upload images for the 4th part of the surgical technique. The images should clearly illustrate the actions performed, instruments utilized, and techniques applied during this phase.

Case Overview Part 4: Image Description(s)*

Detail the 4th part of the surgical case. Include specific actions, instruments, and techniques used. Please reference images associated with the specific surgical case to provide a clear understanding of this part.

Would You Like to Add a 5th Part to the Case Overview?*

NoYes

Case Overview Part 5: Image(s)*

Please upload images for the 5th part of the surgical technique. The images should clearly illustrate the actions performed, instruments utilized, and techniques applied during this phase.

Case Overview Part 5: Image Description(s)*

Detail the 5th part of the surgical case. Include specific actions, instruments, and techniques used. Please reference images associated with the specific surgical case to provide a clear understanding of this part.

Would You Like to Add a 6th Part to the Case Overview?*

NoYes

Case Overview Part 6: Image(s)*

Please upload images for the 6th part of the surgical technique. The images should clearly illustrate the actions performed, instruments utilized, and techniques applied during this phase.

Case Overview Part 6: Image Description(s)*

Detail the 6th part of the surgical case. Include specific actions, instruments, and techniques used. Please reference images associated with the specific surgical case to provide a clear understanding of this part.

Would You Like to Add a 7th Part to the Case Overview?*

NoYes

Case Overview Part 7: Image(s)*

Please upload images for the 7th part of the surgical technique. The images should clearly illustrate the actions performed, instruments utilized, and techniques applied during this phase.

Case Overview Part 7: Image Description(s)*

Detail the 7th part of the surgical case. Include specific actions, instruments, and techniques used. Please reference images associated with the specific surgical case to provide a clear understanding of this part.

Would You Like to Add a 8th Part to the Case Overview?*

NoYes

Case Overview Part 8: Image(s)*

Please upload images for the 8th part of the surgical technique. The images should clearly illustrate the actions performed, instruments utilized, and techniques applied during this phase.

Case Overview Part 8: Image Description(s)*

Detail the 8th part of the surgical case. Include specific actions, instruments, and techniques used. Please reference images associated with the specific surgical case to provide a clear understanding of this part.

Would You Like to Add a 9th Part to the Case Overview?*

NoYes

Case Overview Part 9: Image(s)*

Please upload images for the 9th part of the surgical technique. The images should clearly illustrate the actions performed, instruments utilized, and techniques applied during this phase.

Case Overview Part 9: Image Description(s)*

Detail the 9th part of the surgical case. Include specific actions, instruments, and techniques used. Please reference images associated with the specific surgical case to provide a clear understanding of this part.

Would You Like to Add a 10th Part to the Case Overview?*

NoYes

Case Overview Part 10: Image(s)*

Please upload images for the 10th part of the surgical technique. The images should clearly illustrate the actions performed, instruments utilized, and techniques applied during this phase.

Case Overview Part 10: Image Description(s)*

Detail the 10th part of the surgical case. Include specific actions, instruments, and techniques used. Please reference images associated with the specific surgical case to provide a clear understanding of this part.

Would You Like to Add a 11th Part to the Case Overview?*

NoYes

Case Overview Part 11: Image(s)*

Please upload images for the 11th part of the surgical technique. The images should clearly illustrate the actions performed, instruments utilized, and techniques applied during this phase.

Case Overview Part 11: Image Description(s)*

Detail the 11th part of the surgical case. Include specific actions, instruments, and techniques used. Please reference images associated with the specific surgical case to provide a clear understanding of this part.

Would You Like to Add a 12th Part to the Case Overview?*

NoYes

Case Overview Part 12: Image(s)*

Please upload images for the 12th part of the surgical technique. The images should clearly illustrate the actions performed, instruments utilized, and techniques applied during this phase.

Case Overview Part 12: Image Description(s)*

Detail the 12th part of the surgical case. Include specific actions, instruments, and techniques used. Please reference images associated with the specific surgical case to provide a clear understanding of this part.

Post-Op: Image(s)*

Please upload the post-operative x-ray images for the patient. These images should clearly show the areas treated during the surgery, highlighting the surgical outcomes. Ensure that the images are of high quality and include multiple views if necessary to provide a comprehensive understanding of the patient's post-operative condition.

Post-Op: Protocol Description*

Describe the recovery plan for the patient following surgery. Include details about pain management, physical therapy, activity and weight-bearing restrictions, wound care, and use of supportive devices. Please reference the post-operative results.

Follow-Up: Image(s)*

Please upload any follow-up images taken during the patient's recovery period. These images should document the healing process and show the progress made post-surgery. Ensure that the images are clear and provide multiple views if necessary to give a comprehensive understanding of the patient's recovery.

Follow-Up: Description(s)*

Provide a summary of the patient's condition and progress following the surgery. Include details on recovery milestones, any complications encountered, the effectiveness of the treatment, and the patient's overall outcomes at follow-up appointments. Please reference the follow-up images to give a clear picture of the patient's recovery period.