MOON / MARS STUDY SURGEON FORM · 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

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

bmann

Text Box

SAMPLE ONLY - DO NOT USE

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):


Page 6

a. INVOLVED:

b. Uninvolved:

0 0 0 0 0743

ProneSupine

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)


b. External Rotation Test (90 deg. flexion)


a. External Rotation Test (30 deg. flexion)


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


Page 7

(side-to-side comparison)



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:




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


"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: __________________________


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


NoYes

--- Otherwise, please proceed to Section E (page 26) ---


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


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


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


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


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


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


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%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


0 0 0 0 0743

F. Lateral Meniscus Tear #1



88. LOCATION:

If NO tear, proceed to Section G (page 32)


89. IS THE TEAR CENTRAL OR ADJACENT TO THE POPLITEAL HIATUS?

NoYes

90. TYPE:

.

NoYes


RadialObliqueLongitudinal (vertical)Bucket handle (displaced)HorizontalComplex

Yes (proceed to question #87b)

Yes (proceed to question #98)

Page 29



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


None33%67%100%



93. TREATMENT: No treatment for tearExcisionRepairAbrade + trephineMeniscus transplant

F. Lateral Meniscus Tear #1 (cont'd)

Page 30


a. Posterior

b. Anterior



0 0 0 0 0743

Inside-outOutside-inAll-inBoth inside-out and all-inOther

Absorbable sutureNonabsorbable sutureAbsorbable stint or implant - name ______________________


None33%67%100%


F. Lateral Meniscus Tear #1 (cont'd)

For Additional Lateral Meniscal Pathology, also complete Section M (page 41)

Page 31


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



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


NoYes

NoYes


0%25%50%75%100%

NoneChondroplasty (debride loose art. cartilage only)Abrasion arthroplasty (debride into bone)MicrofractureMosaicplastyCell RxAllograftThermalOther: __________________________

NoYes


Sagittal (A to P)Coronal (M to L)

Page 34




mm


116. DIMENSIONS OF LARGEST LESION:

Length:

Width: mm

mm

115. DEGREES ON CONDYLE SURFACE: (from anterior to posterior)

degrees


a. Acute (Traumatic) b. Degenerative c. Grade

112. IS AN ARTICULAR LESION PRESENT ON THE MEDIAL FEMORAL CONDYLE?


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


H. LTP -- Articular Lesions

NoYes

NoYes


0%25%50%75%100%

NoneChondroplasty (debride loose art. cart. only)Abrasion arthroplasty (debride into bone)MicrofractureMosaicplastyCell RxAllograftThermalOther: __________________________


Yes

0%25%50%75%100%

NoYes


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?


130. TREATMENT FOR THE ARTICULAR CARTILAGE FRACTURES:



mm

127b. NUMBER OF FRACTURES:#0 - 9 (maximum)


125. % OF ANTERIOR-TO-POSTERIOR:


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


NoYes

NoYes


0%25%50%75%100%

NoneChondroplasty (debride loose art cart only)Abrasion arthroplasty (debride into bone)MicrofractureMosaicplastyCell RxAllograftThermalOther: __________________________

0%25%50%75%100%

NoYes


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?





134. % OF ANTERIOR-TO-POSTERIOR:


136b. NUMBER OF FRACTURES:

#0 - 9 (maximum)


mm


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


NoYes

NoYes


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




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


NoYes

NoYes


NoYes

RIGHT LEFT

149. WORST Grade Chondromalacia of each section involved via Outerbridge scale using "1,2,3,4"

TrochlearRegion

Page 38




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



151. LOCATION:


If NO tear, proceed to Section M (page 41)

NoYes


155. TREATMENT:

RadialObliqueLongitudinal (vertical)Bucket handle (displaced)HorizontalComplex

.

Yes

Page 39


153. LENGTH (in mm):

152. TYPE:



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



None33%67%100%

IntactDisrupted


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






if any implant, please check next box.

0 0 0 0 0743

M. Lateral Meniscus Tear #2



If NO tear, proceed to Section N (page 43)


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:



163. IS THE TEAR CENTRAL OR ADJACENT TO THE POPLITEAL HIATUS?

165. LENGTH (in mm):


mm


167. TREATMENT:

0 0 0 0 0743


Inside-outOutside-in

All-inBoth inside-out and all-inOther

NoneAbsorbable sutureNonabsorbable sutureAbsorbable stint or implant - name _____________________________

Quantify extent of CURRENT EXCISION:


None33%67%100%


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







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




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




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

Documents

MOON / MARS STUDY SURGEON FORM · 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