CONSENT / Issue | 1

CONSENT FOR PERFORMING KNEE ARTHROSCOPY

Witnesses present(to be filled out in the event of an oral consent if written consent is not possible):

Witness 1: Name and surname, Personal Identification Number: …………………………………………………………..

Witness 2: Name and surname, Personal Identification Number: …………………………………………………………..

Reason for inability or refusal of written consent: ……………………………………………………………………………….. ..…………………………………………………………………………………………………………………………………………......

Statutory representatives(to be filled out in the event the person to be operated on is a minor or a mental health disorder):

Representative 1: Name and surname, Personal Identification Number: ………………………………………………..

Representative 2: Name and surname, Personal Identification Number: ………………………………………………..

Affected side: Right Left

The recommended surgical procedure shall be performed for the purposes of:

diagnostic arthroscopy

damaged or degenerative tear of meniscus

cartilage damage

kneecap-related issues

synovectomy

reconstruction of the anterior cruciate ligament

 other: ......

Description of the surgery procedure (a more detailed description of the procedure is available in the Patient Information):

  1. Surgery is performed under local, spinal or general anaesthesia. The procedure of carrying out the anaesthesia and anaesthesia-related complications are described in more detail in the form for consenting to anaesthesia. You will receive answers to your questions and any uncertainties by a specialist doctor anaesthetist who will perform the procedure on you.
  2. During the surgery, an endoscopic camera optical instrument is inserted into the knee joint which enables the examination of the inside of the joint.
  3. The endoscopic camera is used to examine the joint structures such as cartilage, cruciate ligaments, meniscus, knee cap.
  4. Structures found to be damaged or abnormal are repaired with a suitable procedure such as partial removal of damaged tissue, smoothing or reconstruction which enables the joint function to improve once again.
  5. In case there are any degenerative bone growths in the joint, they can be removed with grinding.
  6. In some cases due to the limited damage of cartilage the area can be revitalized by drilling the bone which triggers partial cartilage regeneration.
  7. In some arthroscopic procedures a regional blood stasis is required during the procedure to enable better view of the joint and to stop the bleeding. It can be achieved by using a pneumatic tourniquet that is placed on the thigh which is thus compressed so that the blood circulation of the leg is temporarily stopped.

Expected benefits of the recommended surgery:

  1. elimination or decrease if pain in the knee
  2. improved of the range of active knee mobility and cessation of knee swelling
  3. improved knee stability

You will find out to what extend you can expect the above benefits related to the performed surgery depending on the pre-surgery condition of the knee joint and possible related diseases from the doctor that will perform the procedure.

Notes of the doctor who has the duty to provide explanation: …………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…...... …………………………………………………………………………………………………………………………………………………………

Risks related to the recommended surgery:

  1. Every surgery procedure can cause unwanted bleeding in the area where the procedure is performed. The probability of the arthroscopic procedure causing heavy bleeding that would require hospital treatment and transfusion is extremely low.
  2. During each surgery procedure, there is the possibility of a bacterial infection occurring which can cause the suppuration of the wound or a bacterial infection of the joint. To lower the risk of perioperative infection in some cases the patient might receive a preventive antibiotic before the surgery. If infection of the joint or the surgery wound occurs, a long-term treatment with antibiotics is required and in some cases one or more surgical procedures involving rinsing of the joint and removing the suppurated and infected soft tissue are required.
  3. During a diagnostic arthroscopic examination of the inside of the joint additional unexpected damage in the joint can be determined during the procedure which might require additional surgical procedures to be performed.
  4. Repeat occurrence of the issues. Despite the fact that arthroscopic procedures on the knee are generally very successful, it is not possible to ensure with certainty that it will successfully remove all issues. Despite a professional and quality performance of the surgical procedure, your issues can persist even after the procedure, can reappear or in exceptional circumstances can be worse than before the procedure.
  5. The damage of nerves, blood vessels, ligaments or muscles in the area of the knee joint. Such injuries are extremely rare, but can nonetheless occur. In this case, the injuries are permanent only in exceptional circumstances. Such injuries can result in loss of strength in a certain part of the leg or knee, loss of sense of touch, loss of use of the leg or knee or chronic pain in the leg or knee. Any pre-existent nerve damage does not improve after such a surgical procedure or can even deteriorate. After the surgery, a feeling of burning pain, paresthesia or hypersensitivity can develop in the leg.
  6. Instrument-related complications. Instruments such as camera, tissue shavers, various sensors and clips can be damaged in the joint and parts of instruments can break and remain in the joint. This requires the removal of the broken part of the instrument from the joint. Such particles can also cause damage to the joint which can be permanent and severe.
  7. After the surgical procedure, a chronic pain in the joint can develop.
  8. Muscle weakness and limited joint mobility. This does not occur directly due to the procedure, but because of unsuitable post-operative rehabilitation. Long-term limited joint mobility and/or muscle weakness can require the post-operative rehabilitation to be extended or, exceptionally, and additional surgery. Joint stiffening and decrease of muscle strength of the joint could also be permanent.
  9. The knee arthroscopy is a surgical procedure that requires the use of technically complex surgery equipment. Despite top quality medical equipment that was manufactured by taking into account all safety standards equipment failure during the surgery is possible, which in exceptional circumstances in a worst case scenario can prevent the planned performance of the surgical procedure and requires the surgery to be terminated. In this case, an additional surgery or a repeat of the surgical procedure might be required at a later date.
  10. Risks and complications related to anaesthesia are explained in the Consent to Anaesthesia form.

Despite the fact that it is extremely unlikely it is nonetheless possible complications, such as a myocardial infarction, a stroke, development of blood clots with resulting blood vessel blockage and even death during or after surgery, can arise. The risk that such events develop in your case depends on your general health condition, age and other accompanying diseases. Any of these complications could develop with or without prior warning signs. Elevated blood pressure, diabetes, age over 65, past recovery after a myocardial infraction, recovery after conditions with blood clots, recovery after stroke, smoking and previous heart surgeries are only some of the conditions that increase such risk. Other accompanying diseases that you have can increase the risk for some of the complications listed above.

Every person is unique and can possess some of the additional risk factors due to their health condition, the way of life or the level of physical activity. Risk factors for per-operative or post-operative complications that apply to you are: (suitable selection is encircled by your doctor)

  1. diabetes
  2. smoking
  3. obesity
  4. poor general physical condition
  5. excessive alcohol consumption
  6. age above 65
  7. Other: ......

Other treatment options:

  1. You could acquiesce with the knee injury and get used to the limited knee function.
  2. You can continue physical therapy which in time might somewhat mitigate your issues with the knee or improve the knee function.
  3. Local corticosteroid injections into the joint can in some cases decrease the pain in the joint, but have side effects and only allow limited use.
  4. You could take analgesics/anti-inflammatory drugs that will decrease the pain in your knee.

Post-surgery plan:

The surgical procedure is only a part of the process of treating your knee injury. After the surgery, a longer intensive physical therapy will be required that in some cases must last up to 6 months after surgery. To ensure the highest possible successfulness of the performed surgery, it is required to carefully comply with instructions after the surgery and the post-operative rehabilitation protocol. Not cooperating in the post-operative rehabilitation process could result in deterioration of the knee function in comparison with the condition before surgery.

The statement of consent to the knee arthroscopy surgical procedure:

In an interview, the doctor exhaustively and in an intelligible way explained the nature of my knee injury. For the recommended surgical operation I received written explanations with information on the expected development and consequences of the knee disease or injury and with described goals, type, performance method and probability of success and expected benefits of the recommended surgical operation. I have been informed with the advantages and risks and possible complications related to the recommended surgical method of treatment as well as with other options of continuing treatment. I agree that other required medical personnel can participate in the implementation of the surgical procedure such as an assistant doctor, perioperative nurse and an attendant. I have received satisfactory answers to all my questions; therefore with my signature I am confirming the consent for the performance of the knee arthroscopy. I have been informed that I have the right to revoke the consent for the recommended procedure at any time.

Patient signature:......

Signature of the witnesses or statutory representatives: ......

Doctor’s name and surname: ...... Doctor’s signature: …………….………………

Assistant’s name and surname: ...... Assistants signature: …………….……..……

Date of consent: ...... Time of consent: …………......

Information forwarding:

Persons for whom I am allowing the information to be forwarded to regarding my health condition and the course of the planned surgical procedure:

Person 1: Name and surname, relation, phone: ……………………………………………………………………………………..

……………………………………………………………………......

Person 2: Name and surname, relation, phone: …………………………………………………………………......

……………………………………………………………………......

SOG.05/10 / Artros d.o.o, Tehnološki park 21, 1000 Ljubljana, D.Š.:SI29365678 Page | 1