Appendix 1

Fusion Followup

PROCEED TO THE FOLLOWING QUESTIONS ONLY AFTER CONSENT IS GIVEN:

Q1) YES ___ NO ____ (IF NO, STOP) Is it correct that you had a knee fusion?

Q2) Date: _____/ ______/______When was it performed?

month/ day / year

Q3a) YES___ NO ___ Didyou have a TKA on the knee before fusion?

Q3b) If yes, what date was your original knee arthroplasty done? Date: _____/_____/_____ month/ day /year

Q4) YES ____ NO ____ Did this knee replacement become infected?

Q4a) If your knee DID NOT become infected, please explain why the knee was fused.

______

Q5) YES___ NO ___ If your knee became infected, are you currently taking antibiotics

for your knee?

Q6) Total # ______How many total surgeries have you had on the involved knee?

Use the table below to list each surgery and the date of that surgery. Complete to the best of your ability. We do understand that you may have had multiple procedures, and these data may not be easy to recall.

Date / Surgery / Surgeon / Hospital

THE FOLLOWING 3 QUESTIONS ARE ABOUT FUNCTION BEFORE THE KNEE INFECTION

Q7a) Just before your knee fusion, how would you characterize your ability to walk?

1.) Able to walk outside of the house, unlimited distance

2.) Able to walk outside the house, < five blocks

3.) Able to walk around the house only

4.) Only use your legs to get in and out of bed, out of chair, or the bathroom

5.) Not able to walk at all

Q7b) If you were able to walk before your knee fusion, did you require an aid to get around?

1.) No ambulatory aid

2.) Cane

3.) Crutches

4.) Walker

Q7c) Before your knee fusion, where did you live?

1.) In your own house, without assistance

2.) In your house, with outside assistance (from family or home care nurses, etc)

3.) In an assisted living facility

4.) In a nursing home

THE FOLLOWING QUESTIONS ARE ABOUT FUNCTION AFTER YOUR KNEE FUSION

Q8a) After your knee fusion, how well were you able to walk?

1.) Able to walk outside of the house, unlimited distance

2.) Able to walk outside the house, < five blocks

3.) Able to walk around the house only

4.) Only use your legs to get in and out of bed, out of chair, or the bathroom

5.) Not able to walk at all

Q8b) If you were able to ambulate after your knee fusion, did you require an aid to get around?

1.) No ambulatory aid

2.) Cane

3.) Crutches

4.) Walker

Q8c) After your knee fusion, where did you live?

1.) In your own house, without assistance

2.) In your house, with outside assistance (from family or home care nurses, etc)

3.) In an assisted living facility

4.) In a nursing home

Q9) YES _____NO____ If you could do it again, would you have your knee fusion?

Q10) On a scale from 0 to 10, how would you rate the pain in your fusion leg?

012345678910

Q11) Did you have to have any additional surgeries on your leg after your knee fusion? Check all that apply.

1.) No

2.) Yes, washout of the wound

3.) Yes, revision fusion

4.) Yes, above knee amputation

5.) Other: ______

Q12) If YES to question 11, how many surgeries have you had on your leg after your knee fusion?

______(number)

Q13) Do you have any problems with your other leg that keeps you from walking around?

1.) Yes

2.) No

Q13a) If you answered yes to question 13, please explain what problem you have with your other leg:

______

Thank you for your time.