Check One Box That Best Describes Your Current Activity Level

DIVISION OF ORTHOPAEDIC SURGERY

RESEARCH

Marc Richard, M.D.

James Urbaniak, M.D.

Dear Orthopaedic Patient:

We hope that this letter finds you doing well. We are contacting all of the patients who have undergone the free vascularized fibular graft (FVFG) procedure at Duke University as treatment for avascular necrosis (AVN) of the hip. As you may know, the free vascularized fibular graft procedure was pioneered by Dr. James Urbaniak at Duke in 1979. Together with his partner, Dr. Mack Aldridge, over 2,700 free vascularized fibular graft procedures have been performed by the Duke Team.

We have continued to witness wonderful results from this procedure in patients of varying ages and with various degrees of AVN; however our success rate is not 100%. In an attempt to improve our outcomes we are doing a research study to examine thoroughly the cases we have already performed in hopes of finding a common thread for those cases that have succeeded and for those that have not.

With your permission and cooperation, we would appreciate your participation in this project. In order to participate, all we require from you is the completion of the short questionnaire attached to this letter. Approximately 2 weeks after you receive this packet, a member the research staff will contact you by phone to discuss the study and answer any questions you might have.

Attached to this letter and the questionnaire you will also find two consent forms with all the details of this study. Once you have spoken with a member of the research staff, please return one of the consent forms signed, initialed and dated and have another adult sign as a witness.

Be assured that all of your information will be kept confidential. Only the physicians involved in this project will have access to your questionnaire. With your help we will be able to obtain results that will provide important information for both physicians and patients.

Thank you for taking the time to read this letter, and thank you in advance for your willingness to participate in this important research. If you have any questions or concerns please do not hesitate to call us at (919)403-5162.

We hope this letter finds you in good health, and we look forward to hearing from you soon.

Sincerely,

Marc Richard, MD

James Urbaniak, MD

Division of Orthopaedic Surgery

Duke University Medical Center

ther person or entity, except as required by law, for authorized oversight of the research study.

Check one box that best describes your current activity level.
? 1: Wholly inactive, dependent on others, and can not leave residence
? 2: Mostly inactive or restricted to minimum activities of daily living
? 3: Sometimes participates in mild activities, such as walking, limited housework and limited shopping
? 4: Regularly participates in mild activities
? 5: Sometimes participates in moderate activities such as swimming or could do unlimited housework or shopping
? 6: Regularly participates in moderate activities
? 7: Regularly participates in active events such as bicycling
? 8: Regularly participates in active events, such as golf or bowling
? 9: Sometimes participates in impact sports such as jogging, tennis, skiing, acrobatics, ballet, heavy labor or backpacking
? 10: Regularly participates in impact sports

A modified Harris Hip Score questionnaire was completed by each patient (not reprinted here due to copyright law).

Have you had any hip surgery or hip procedures since your free vascularized fibular procedure at Duke?

□NO

□YES (please list below)

OPERATIONDate of Operation

______

______

______

______

______

Do you currently use opiate pain medication (e.g. vicodin, hydrocodone, percocet, oxycodone, oxycontin, dilaudid, darvocet, morphine, methadone, codeine, demerol, etc.) for the relief of pain from your operative hip?

□NO

□YES