ID

28923

Description

Evalution of ACL reconstruction. References: Feagin Jr, J. A., & Blake, W. P. (1983). Postoperative evaluation and result recording in the anterior cruciate ligament reconstructed knee. Clinical Orthopaedics and Related Research®, 172, 143-147. Blake, W. P.: Personal communication, Gainesville Orthopaedic Group, Gainesville, Florida, 1980. Cohen, L. L.: Personal communication, Santa Fe

Keywords

Versions (3)
  1. 2/16/18 2/16/18 -
  2. 2/20/18 2/20/18 -
  3. 5/9/18 5/9/18 - Halim Ugurlu
Copyright Holder

Feagin Jr, J. A.; Blake, W. P.

Uploaded on

February 16, 2018

DOI

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License

Creative Commons BY-NC 3.0
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Anterior cruciate ligament follow-up form

English

Anterior cruciate ligament follow-up form

1 forms  
Identification
Description

Identification

Date
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008
Last Name
Description

Last Name

Data type

text

Alias
UMLS CUI [1]
C1301584
First Name
Description

First Name

Data type

text

Alias
UMLS CUI [1]
C1443235
Initials
Description

Patient Initials

Data type

text

Alias
UMLS CUI [1]
C2986440
SS #
Description

Social Security number

Data type

integer

OFF #
Description

OFF number

Data type

text

Age
Description

Age

Data type

integer

Measurement units
  • years
Alias
UMLS CUI [1]
C0001779
years
Sex
Description

Sex

Data type

text

Alias
UMLS CUI [1]
C0079399
Knee involved
Description

Knee involved

Data type

text

Phone #
Description

Phone number

Data type

integer

Name of someone who can reach you if you have moved
Description

Name of close person

Data type

text

Phone # of someone who can reach you if you have moved
Description

Phone number of close person

Data type

integer

Date of surgery
Description

Date of surgery

Data type

date

Number of months since surgery
Description

Number of months since surgery

Data type

integer

Post-OP course
Description

Post-OP course

Cast?
Description

Cast

Data type

boolean

# weeks in rigid cast
Description

duration rigid cast

Data type

integer

# weeks in flexible/hinged cast
Description

duration flexible/hinged cast

Data type

integer

Brace?
Description

Brace

Data type

boolean

Current brace use?
Description

Current brace use

Data type

text

Physical Therapy?
Description

Physical Therapy

Data type

boolean

# months in supervised program (Cybex Ortholron etc.)
Description

supervised physical therapy duration

Data type

integer

Are you still doing a regular home program?
Description

physical therapy home program

Data type

boolean

Symptoms
Description

Symptoms

Knee pain?
Description

Knee pain

Data type

integer

Giving way?
Description

Giving way

Data type

integer

Swelling?
Description

Swelling

Data type

integer

Stiffness?
Description

Stiffness

Data type

integer

Symptom Total points
Description

total points symptoms

Data type

integer

Symptom Summary = Total / 4
Description

Symptom Summary

Data type

integer

Function
Description

Function

Activity level?
Description

Activity level

Data type

integer

Function Summary (Activity level)
Description

function summary

Data type

integer

Problems with specific activities: Walking?
Description

Walking

Data type

text

Problems with specific activities: Running?
Description

Running

Data type

text

Problems with specific activities: Turn/Cut?
Description

Turn/Cut

Data type

text

Problems with specific activities: Jumping?
Description

Jumping

Data type

text

Problems with specific activities: Stairs?
Description

Stairs

Data type

text

If your prior injury activity level rates at 10, what does your current activity level rate?
Description

rating activity level

Data type

integer

If your normal knee performs 100%, at what % does your operated knee perform?
Description

rating knee performance

Data type

integer

Measurement units
  • %
%
Surgical Hx
Description

Surgical Hx

Type ACL Injury
Description

Type ACL Injury

Data type

text

Associated injury (acute or chronic)
Description

Associated injury

Data type

text

ACL Surgery
Description

ACL Surgery

Data type

text

Primary Repair Aug with
Description

ACL Surgery Primary repair

Data type

text

Reconstruction with
Description

ACL Surgery Reconstruction

Data type

text

Subsequent Injury
Description

Subsequent Injury

Data type

text

Subsequent Surgery
Description

Subsequent Surgery

Data type

text

Stability
Description

Stability

Anterior Drawer / Lachman: Right leg, 15°
Description

record as 0 tr 1+ 2+ 3+

Data type

text

Anterior Drawer / Lachman: Right leg, 90°
Description

record as 0 tr 1+ 2+ 3+

Data type

text

Anterior Drawer / Lachman: Left leg, 15°
Description

record as 0 tr 1+ 2+ 3+

Data type

text

Anterior Drawer / Lachman: Left leg, 90°
Description

record as 0 tr 1+ 2+ 3+

Data type

text

Subluxation (Pivot shift, Jerk, etc.): Right leg
Description

record as 0 tr 1+ 2+ 3+

Data type

text

Subluxation (Pivot shift, Jerk, etc.): Left leg
Description

record as 0 tr 1+ 2+ 3+

Data type

text

Varus: Right leg, 0°
Description

Varus right 0 degrees

Data type

text

Varus: Right leg, 30°
Description

Varus right 30 degrees

Data type

text

Varus: Left leg, 0°
Description

Varus left 0 degrees

Data type

text

Varus: Left leg, 30°
Description

Varus left 30 degrees

Data type

text

Valgus: Right leg, 0°
Description

Valgus right 0 degrees

Data type

text

Valgus: Right leg, 30°
Description

Valgus right 30 degrees

Data type

text

Valgus: Left leg, 0°
Description

Valgus left 0 degrees

Data type

text

Valgus: Left leg, 30°
Description

Valgus left 30 degrees

Data type

text

Range of motion: Right leg
Description

Range of motion right

Data type

integer

Measurement units
  • °
°
Range of motion: Left leg
Description

Range of motion left

Data type

integer

Measurement units
  • °
°
Additional studies: X-ray
Description

Additional studies: X-ray

Med joint DJD
Description

X-ray Med joint DJD

Data type

text

Lat joint DJD
Description

X-ray lat joint DJD

Data type

text

P/F joint DJD
Description

X-ray P/F joint DJD

Data type

text

ICN osteophytes
Description

X-ray ICN osteophytes

Data type

text

Other (your favorite test)
Description

Other X-ray

Data type

text

Additional studies: Cybex/Orthotron (if available)
Description

Additional studies: Cybex/Orthotron (if available)

Strength
Description

Strength

Data type

text

Power
Description

Power

Data type

text

Thigh Circ: Right leg (10cm patella)
Description

Thigh Circ right

Data type

text

Thigh Circ: Left leg (10cm patella)
Description

Thigh Circ left

Data type

text

Capsule summary
Description

Capsule summary

Symptoms
Description

The Symptom score is the total score /4 of the entire symptom section

Data type

integer

Function
Description

The Function score is the score of the activity level question only

Data type

integer

Stability
Description

The Stability score comes from only the Ant Draw/Lach/Sublux portion of the P.E. as follows 5=none of the 3 tests > trace; 4=none of the 3 tests > 1 +; 3=two tests 1+ one test 2+; 2=two tests 2+ one test 1+; 1=all tests >= 2+.

Data type

integer

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Similar models

Anterior cruciate ligament follow-up form

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Identification
Date
Item
Date
date
C0011008 (UMLS CUI [1])
Last Name
Item
Last Name
text
C1301584 (UMLS CUI [1])
First Name
Item
First Name
text
C1443235 (UMLS CUI [1])
Patient Initials
Item
Initials
text
C2986440 (UMLS CUI [1])
Social Security number
Item
SS #
integer
OFF number
Item
OFF #
text
Age
Item
Age
integer
C0001779 (UMLS CUI [1])
Item
Sex
text
C0079399 (UMLS CUI [1])
Sex
Code List
Sex
CL Item
M (M)
CL Item
F (F)
Item
Knee involved
text
Knee involved
Code List
Knee involved
CL Item
Right (Right)
CL Item
Left (Left)
Phone number
Item
Phone #
integer
Name of close person
Item
Name of someone who can reach you if you have moved
text
Phone number of close person
Item
Phone # of someone who can reach you if you have moved
integer
Date of surgery
Item
Date of surgery
date
Item
Number of months since surgery
integer
Number of months since surgery
Code List
Number of months since surgery
CL Item
6 (1)
CL Item
12 (2)
CL Item
18 (3)
CL Item
24 (4)
CL Item
36 (5)
Item Group
Post-OP course
Cast
Item
Cast?
boolean
duration rigid cast
Item
# weeks in rigid cast
integer
duration flexible/hinged cast
Item
# weeks in flexible/hinged cast
integer
Brace
Item
Brace?
boolean
Item
Current brace use?
text
Current brace use
Code List
Current brace use?
CL Item
Allt the time (Allt the time)
CL Item
Sports only (Sports only)
CL Item
No longer use (No longer use)
Physical Therapy
Item
Physical Therapy?
boolean
supervised physical therapy duration
Item
# months in supervised program (Cybex Ortholron etc.)
integer
physical therapy home program
Item
Are you still doing a regular home program?
boolean
Item Group
Symptoms
Item
Knee pain?
integer
Knee pain
Code List
Knee pain?
CL Item
None (4)
CL Item
Mild (3)
CL Item
Moderate (with activity) (2)
CL Item
Severe (at rest and preventing activity) (1)
Item
Giving way?
integer
Giving way
Code List
Giving way?
CL Item
None (8)
CL Item
Only with cutting (stop and turn) sports (6)
CL Item
Occasional (only with awkward step) (4)
CL Item
With normal daily activities (2)
Item
Swelling?
integer
Swelling
Code List
Swelling?
CL Item
None (4)
CL Item
Strenuous activity (3)
CL Item
With moderate activity (2)
CL Item
With any activity (1)
Item
Stiffness?
integer
Stiffness
Code List
Stiffness?
CL Item
None (4)
CL Item
Occasional (2)
CL Item
Frequent (1)
total points symptoms
Item
Symptom Total points
integer
Symptom Summary
Item
Symptom Summary = Total / 4
integer
Item Group
Function
Item
Activity level?
integer
Activity level
Code List
Activity level?
CL Item
No sports  (1)
CL Item
Sports activities significantly limited (2)
CL Item
Active, but different sports (3)
CL Item
Same sports, but lower performance level  (4)
CL Item
Equal performance at same sports as before injury (5)
function summary
Item
Function Summary (Activity level)
integer
Item
Problems with specific activities: Walking?
text
Walking
Code List
Problems with specific activities: Walking?
CL Item
None (None)
CL Item
Mild (Mild)
CL Item
Moderate (Moderate)
CL Item
Severe (Severe)
Item
Problems with specific activities: Running?
text
Walking
Code List
Problems with specific activities: Running?
CL Item
None (None)
CL Item
Mild (Mild)
CL Item
Moderate (Moderate)
CL Item
Can't do (Can't do)
Item
Problems with specific activities: Turn/Cut?
text
Walking
Code List
Problems with specific activities: Turn/Cut?
CL Item
None (None)
CL Item
Mild (Mild)
CL Item
Moderate (Moderate)
CL Item
Can't do (Can't do)
Item
Problems with specific activities: Jumping?
text
Walking
Code List
Problems with specific activities: Jumping?
CL Item
None (None)
CL Item
Mild (Mild)
CL Item
Moderate (Moderate)
CL Item
Can't do (Can't do)
Item
Problems with specific activities: Stairs?
text
Walking
Code List
Problems with specific activities: Stairs?
CL Item
None (None)
CL Item
Mild (Mild)
CL Item
Moderate (Moderate)
CL Item
Can't do (Can't do)
rating activity level
Item
If your prior injury activity level rates at 10, what does your current activity level rate?
integer
rating knee performance
Item
If your normal knee performs 100%, at what % does your operated knee perform?
integer
Item Group
Surgical Hx
Item
Type ACL Injury
text
Type ACL Injury
Code List
Type ACL Injury
CL Item
Acute (< 1 wk) (Acute (< 1 wk))
CL Item
Sub Acute (1-6 wks) (Sub Acute (1-6 wks))
CL Item
Chronic (>6 wks) (Chronic (>6 wks))
CL Item
Acute on Chronic (Acute on Chronic)
Item
Associated injury (acute or chronic)
text
Associated injury
Code List
Associated injury (acute or chronic)
CL Item
MCL (MCL)
CL Item
PCL (PCL)
CL Item
LCL (LCL)
CL Item
Med Men (Med Men)
CL Item
Lat Men (Lat Men)
Item
ACL Surgery
text
ACL Surgery
Code List
ACL Surgery
CL Item
No repair (No repair)
CL Item
Primary Repair without Augmentation (Primary Repair without Augmentation)
CL Item
Primary Repair Aug (Primary Repair Aug)
CL Item
Reconstruction (Reconstruction)
ACL Surgery Primary repair
Item
Primary Repair Aug with
text
ACL Surgery Reconstruction
Item
Reconstruction with
text
Item
Subsequent Injury
text
Subsequent Injury
Code List
Subsequent Injury
CL Item
None (None)
CL Item
Medical Meniscus (Medical Meniscus)
CL Item
Lateral Meniscus (Lateral Meniscus)
CL Item
ACL (ACL)
CL Item
MCL (MCL)
CL Item
LCL (LCL)
CL Item
PCL (PCL)
Item
Subsequent Surgery
text
Subsequent Surgery
Code List
Subsequent Surgery
CL Item
None (None)
CL Item
Hardware removal (Hardware removal)
CL Item
MUA (MUA)
CL Item
Menisectomy (Menisectomy)
CL Item
Ligament repair (Ligament repair)
Item Group
Stability
Anterior Drawer / Lachman right leg 15 degrees
Item
Anterior Drawer / Lachman: Right leg, 15°
text
Anterior Drawer / Lachman right leg 90 degrees
Item
Anterior Drawer / Lachman: Right leg, 90°
text
Anterior Drawer / Lachman left leg 15 degrees
Item
Anterior Drawer / Lachman: Left leg, 15°
text
Anterior Drawer / Lachman left leg 90 degrees
Item
Anterior Drawer / Lachman: Left leg, 90°
text
Subluxation right
Item
Subluxation (Pivot shift, Jerk, etc.): Right leg
text
Subluxation left
Item
Subluxation (Pivot shift, Jerk, etc.): Left leg
text
Varus right 0 degrees
Item
Varus: Right leg, 0°
text
Varus right 30 degrees
Item
Varus: Right leg, 30°
text
Varus left 0 degrees
Item
Varus: Left leg, 0°
text
Varus left 30 degrees
Item
Varus: Left leg, 30°
text
Valgus right 0 degrees
Item
Valgus: Right leg, 0°
text
Valgus right 30 degrees
Item
Valgus: Right leg, 30°
text
Valgus left 0 degrees
Item
Valgus: Left leg, 0°
text
Valgus left 30 degrees
Item
Valgus: Left leg, 30°
text
Range of motion right
Item
Range of motion: Right leg
integer
Range of motion left
Item
Range of motion: Left leg
integer
Item Group
Additional studies: X-ray
Item
Med joint DJD
text
Walking
Code List
Med joint DJD
CL Item
None (None)
CL Item
Mild (Mild)
CL Item
Moderate (Moderate)
CL Item
Severe (Severe)
Item
Lat joint DJD
text
Walking
Code List
Lat joint DJD
CL Item
None (None)
CL Item
Mild (Mild)
CL Item
Moderate (Moderate)
CL Item
Severe (Severe)
Item
P/F joint DJD
text
Walking
Code List
P/F joint DJD
CL Item
None (None)
CL Item
Mild (Mild)
CL Item
Moderate (Moderate)
CL Item
Severe (Severe)
Item
ICN osteophytes
text
Walking
Code List
ICN osteophytes
CL Item
None (None)
CL Item
Mild (Mild)
CL Item
Moderate (Moderate)
CL Item
Severe (Severe)
Other X-ray
Item
Other (your favorite test)
text
Item Group
Additional studies: Cybex/Orthotron (if available)
Strength
Item
Strength
text
Power
Item
Power
text
Thigh Circ right
Item
Thigh Circ: Right leg (10cm patella)
text
Thigh Circ left
Item
Thigh Circ: Left leg (10cm patella)
text
Item Group
Capsule summary
Symptoms
Item
Symptoms
integer
Function
Item
Function
integer
Item
Stability
integer
Stability
Code List
Stability
CL Item
none of the 3 tests > trace (5)
CL Item
none of the 3 tests > 1 + (4)
CL Item
two tests 1+ one test 2+ (3)
CL Item
two tests 2+ one test 1+ (2)
CL Item
all tests >= 2+ (1)
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