Kestrel Buttress Plate System Post Market Surveillance Protocol

Location and Physician

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* 1. Hospital Name

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* 2. Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone Number

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* 3. Physician Name

Patient Demographics

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* 4. Patient Gender

Male

Female

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* 5. Patient Age

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* 6. Patient Weight

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* 7. Patient Height

Procedure

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* 8. Segments (Check all that apply if multiple levels were treated)

L2/L3

L3/L4

L4/L5

L4-S1

L5/S1

Other (please specify)

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* 9. Operation Date and Time

Date / Time

Date

Time

AM/PM

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* 10. Total Operative Time (00:00)

Implants used

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* 11. Instruments used (check any used)

Universal Ratchet Handle

Inserter

Bone Awl

Screw Driver

Plate Bender

Slide Hammer

Mallet

Other (please specify)

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* 12. Kestrel Implant Size

17 x 20mm

17 x 24mm

17 x 28mm

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* 13. Screw Length

20mm

25mm

30mm

6.5 x 20mm rescue screw

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* 14. Rate Each Instrument

	Below Average	Average	Above Average	Exceptional
Universal Ratchet Handle	Universal Ratchet Handle Below Average	Universal Ratchet Handle Average	Universal Ratchet Handle Above Average	Universal Ratchet Handle Exceptional
Inserter	Inserter Below Average	Inserter Average	Inserter Above Average	Inserter Exceptional
Bone Awl	Bone Awl Below Average	Bone Awl Average	Bone Awl Above Average	Bone Awl Exceptional
Screw Driver	Screw Driver Below Average	Screw Driver Average	Screw Driver Above Average	Screw Driver Exceptional
Plate Bender	Plate Bender Below Average	Plate Bender Average	Plate Bender Above Average	Plate Bender Exceptional
Slide Hammer	Slide Hammer Below Average	Slide Hammer Average	Slide Hammer Above Average	Slide Hammer Exceptional
Mallet	Mallet Below Average	Mallet Average	Mallet Above Average	Mallet Exceptional

Please explain any below average ratings.

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* 15. Play in Implant While Engaged to Inserter

Snug

Loose

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* 16. Rate the Implant

	Below Average	Average	Above Average	Exceptional
Ease of Insertion	Ease of Insertion Below Average	Ease of Insertion Average	Ease of Insertion Above Average	Ease of Insertion Exceptional
Size of Implant	Size of Implant Below Average	Size of Implant Average	Size of Implant Above Average	Size of Implant Exceptional

Other (please specify)

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* 17. General Implant

	Yes	No
Was the implant size appropriate?	Was the implant size appropriate? Yes	Was the implant size appropriate? No
Was the Tray Presentation Helpful?	Was the Tray Presentation Helpful? Yes	Was the Tray Presentation Helpful? No

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* 1. Hospital Name

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* 2. Address

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* 3. Physician Name

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* 4. Patient Gender

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* 5. Patient Age

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* 6. Patient Weight

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* 7. Patient Height

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* 8. Segments (Check all that apply if multiple levels were treated)

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* 9. Operation Date and Time

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* 10. Total Operative Time (00:00)

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* 11. Instruments used (check any used)

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* 12. Kestrel Implant Size

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* 13. Screw Length

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* 14. Rate Each Instrument

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* 15. Play in Implant While Engaged to Inserter

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* 16. Rate the Implant

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* 17. General Implant

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* 18. Any other suggestions for possible future improvements?

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* 19. Todays Date

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* 20. Your Name