Document 11646727

 Femoroacetabular Impingement Trial FAIT THEATRE FORM NHS trust Hospital: FAIT STUDY NUMBER FT DATE: (dd/mon/yyyy) Procedure side: Left Right PROCEDURE PERFORMED: (PLEASE TICK) ARTHROSCOPY ONLY LABRAL DEBRIDEMENT ACETABULAR RIM-­‐TRIM FEMORAL NECK OSTEOCHONDROPLASTY LABRAL REPAIR OTHER: ANCHORS NUMBER: MANUFACTURE: (PLEASE POSITION ON PROVIDED DIAGRAM ON THE LAST PAGE) MICROFRACTURE: YES NO ANAESTHETIC: (PLEASE TICK ALL THAT APPLY) GA INDWELLING CATHETER REGIONAL BLOCK INTRA-­‐ARTICULAR INFILTRATION COMBINED ADRENALINE IRRIGATION FLUID Dose: EXTRA-­‐ARTICULAR INFILTRATION Drugs: Dose: Version 1.0 13/06/2013 Page 1 of 6 TOTAL TIME IN THEATRE (INCLUDING ANAESTHETIC): MINS OPERATION TIME: MINS TRACTION TIME: MINS STAFF IN THEATRE: NAME OF OPERATING SURGEON (consultant only): ANAESTHETIST CONSULTANT REGISTRAR SHO NUMBER OF NURSING/ODP STAFF: PATIENT POSITION: SUPINE LATERAL INTRA-­‐OPERATIVE PROBLEMS: ANAESTHETIC PROBLEMS (i.e. respiratory, cardiac, anaphylaxis EQUIPMENT PROBLEMS (i.e. visual display unit, fluid management system, camera, resector, instruments) IMPLANT PROBLEMS (i.e. size unavailable, quantity unavailable) ANY INTRA-­‐OP COMPLICATIONS Please describe: OTHER (i.e. staffing) Please describe: Version 1.0 13/06/2013 Page 2 of 6 CLASSIFICATION OF DAMAGE TO CARTILAGE (modified from Beck et al 2004) DESCRIPTION CRITERIA 0 NORMAL Macroscopically sound cartilage 1 MALACIA Roughening of surface, fibrillation 2 DEBONDING Loss of fixation to the subchondral bone, macroscopically sound cartilage; carpet phenomenon 3 CLEAVAGE Loss of fixation to the subchondral bone; frayed edges, thinning of the cartilage, flap 4 DEFECT Full-­‐thickness defect CLASSIFICATION OF LABRAL DAMAGE DESCRIPTION CRITERIA 0 NORMAL Macroscopically sound labrum 1 DEGENERATION Thinning of localised hypertrophy, fraying, discoloration 2 FULL-­‐THICKNESS Complete avulsion from the acetabular rim TEAR 3 DETATCHMENT Separation between acetabular and labral cartilage, preserved attachment to bone 4 OSSIFICATION Osseous metaplasia, localised or circumferential LIGAMENTUM TERES: NORMAL NOT SEEN PARTIAL TEAR COMPLETE TEAR OTHER STATE:_________________________ TRANSVERSE LIGAMENT: NORMAL NOT SEEN OTHER STATE:_________________________ STELLATE CREASE: ANTERIOR POSTERIOR ABSENT Version 1.0 13/06/2013 Page 3 of 6 SYNOVIUM: NORMAL SYNOVITIS NOT SEEN OTHER STATE:_________________________ LOOSE BODIES: 0 1 2 3 4 5 >5 LOOSE BODY RETRIEVAL: NOT ATTEMPTED COMPLETE INCOMPLETE POST-­‐OPERATION PLAN: TEDS: NO YES DURATION: THROMBOPROPHYLAXIS: CHEMICAL: NO YES DRUG: TIME OF FIRST DOSE: DURATION: MOBILISATION: WEIGHT BEARING STATION: DURATION: RESTRICTION OF MOVEMENT: PLEASE GIVE DETAILS: Version 1.0 13/06/2013 Page 4 of 6 Version 1.0 13/06/2013 Page 5 of 6 Version 1.0 13/06/2013 Page 6 of 6