Joint Registry Nigeria (THR/TKR)

Joint Registry Nigeria (THR/TKR)
Type of Arthroplasty*
Select type of Arthroplasty
If others, specify
PATIENT IDENTIFIER
Patient Name*
Gender*
Contact Number*

Area CodePhone Number
Contact Address*

Street Address

Street Address Line 2

CityState / Country

Postal / Zip Code
Date of Birth*

DayMonthYear
Date
Hospital Identifier
Name of Hospital*

Name of Hospital

Adress of Hospital

StateCountry

Zip CodeCountry
Date of Operation

DayMonthYear
Surgery Date
Type of Anesthesia*
Select Anaesthetic Type
Patient ASA Grade*
Funding*
Select private or corporate
Surgeon Identifier
Surgeon's Name*

PrefixFirst NameMiddle NameLast Name
Grade of Surgeon*
Enter Surgeon's Grade
Name of 1st Surgical Assistant*
Enter 1st Surgical Assistant Name
Grade of 1st Surgical Assistant*
Enter 1st Surgical Assistant Grade
Name of 2nd Surgical Assistant
Enter 1st Surgical Assistant Name
Grade of 2nd Surgical Assistant
Enter 1st Surgical Assistant Grade
Name of Scrub Nurse*
Enter Name of Scrub Nurse
Implant Identifier
Implant vendor
e.g Zimmer, Depuy, etc

THR implant details

	write implant detail
STEM
ACETABULUM
LINER
FEMORAL HEAD
CAGE
OTHERS

Acetabular Cup
Select cemented or Cementless
Stem
Select cemented or Cementless

TKR implant details

	write implant detail
FEMUR
TIBIA
INSERT
FEMORAL STEM
TIBIAL STEM
FEMORAL AUGMENT
TIBIAL AUGMENT
OTHERS

Cement (If Used)
Prophylactic antibiotic used*
Cement Gramage used
Brand of Cement Used
Additional antibiotic used?
Generation of Application (1st, 2nd, 3rd, 4th)
Please explain
Procedure Details
Side*
Diagnosis*
If Others, Specify
Any other diagnosis
Blood Transfusion?
Select Yes or No
Pints of blood used
Enter the number of pints of blood used
Tourniquet Used?*
Tranxemic Acid Used?*
Dosage of Tranxemic Acid used
Enter dosage of Tranxemic Acid used
Tranxemic Acid administration time
Surgical Approach
Previous non THR/TKR surgery(if any)
Procedure*
Select the type of procedure
Positioning
Select the type of positioning
Approach*
Select the type approach
If others, specify
Thromboprophylaxis
In-Hospital
Chemical
Mechanical
If other, specify
Out-of-Hospital
Chemical
Mechanical
If others, specify
Bone Graft
Bone Graft
Type of Bone Graft
Enter type of bonegraft for each side
Intra-Operative Complications*
Should be Empty: