Figure 3: Priority Criteria for Major Joint replacement

(Maximum score 100)

Patient ID:

Pain (40%):

Degree*
None 0
Mild - slight or occasional pain;
patient has not altered patterns of activity or work
4
Moderate - patient is active,
but has had to modify or give up some activities,
or both, because of pain
9
Moderate - severe - fairly severe pain
with substantially limited activities
14
Severe - major pain and serious limitation 20
*Patient must be on maximum medical therapy at time of rating.
Occurrence
None or with first steps only 0
Only after long walks (30 minutes) 4
With all walking, mostly day pain 10
Significant, regular night pain 20
Time Walked
Unlimited 0
31-60 minutes
(eg longer shopping trips to mall)
2
11-30 minutes
(eg gardening, grocery shopping)
4
2-10 minutes
eg trip to letter box
6
Less than 2 minutes or indoors only
(more or less house bound)
8
Unable to walk 10

Functional Activity (20%)

Other functional limitations*
None 0
Mild 2
Moderate 4
Severe 10
*eg putting on shoes, managing stairs, sitting to standing,
sexual activity, recreation or bobbies, walking aids needed

Movement and Deformity (20%)

Pain on examination*
None 0
Mild 2
Moderate 5
Severe 10
*Overall results of both active and passive range of motion
Other abnormal findings*
None 0
Mild 2
Moderate 5
Severe 10
*Limited to orthopaedic problems
eg reduced range of motion, deformity, limp,
instability, progressive x ray findings

Other Factors (20%)

Multiple joint involvement
No, single joint 0
Yes, each affected joint mild - moderate in severity 4
Yes, severe involvement (eg severe rheumatoid arthritis) 10
Ability to work, give care to dependent/s
or live independently
Not threatened or difficult 0
Not threatened but more difficult 4
Threatened but not immediately 6
Immediately threatened 10
*Difficulty must be related to affected joint

Total Score: