MAUDE Adverse Event Report: WALDEMAR LINK GMBH & CO. KG ENDO-MODEL SL; FEMORAL COMPONENT, INTRACONDYLAR MODULAR CEMENTED ROTATIONAL KNEE

Model Number 16-2825/21

Device Problems Detachment of Device or Device Component (2907); Osseointegration Problem (3003)

Patient Problems Bone Fracture(s) (1870); Failure of Implant (1924)

Event Date 05/30/2021

Event Type  Injury  

Manufacturer Narrative

The review of the device history record showed no deviations.The product complies with the specifications valid at the time of manufacture.

Event Description

Dislocation between femoral component and stem [customer].

Event Description

Dislocation between femoral component and stem [customer].

Manufacturer Narrative

The review of the device history record showed no deviations.The product complies with the specifications valid at the time of manufacture.

• Brand Name: ENDO-MODEL SL
• Type of Device: FEMORAL COMPONENT, INTRACONDYLAR MODULAR CEMENTED ROTATIONAL KNEE
• Manufacturer (Section D): WALDEMAR LINK GMBH & CO. KG; barkhausenweg 10; hamburg, 22339 ; GM 22339
• Manufacturer Contact: annerike tizia hucklenbroch ; barkhausenweg 10; hamburg, 22339 ; GM 22339
• MDR Report Key: 12030803
• MDR Text Key: 257138628
• Report Number: 3004371426-2021-00017
• Device Sequence Number: 1
• Product Code: KRO
• Combination Product (y/n): N
• Reporter Country Code: GM
• PMA/PMN Number: K151008
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Foreign,Health Professional
• Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date: 06/11/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Operator: Health Professional
• Device Expiration Date: 08/31/2022
• Device Model Number: 16-2825/21
• Device Catalogue Number: 16-2825/21
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 09/22/2021
• Is the Reporter a Health Professional?: No
• Initial Date Manufacturer Received: 06/11/2021
• Initial Date FDA Received: 06/21/2021
• Supplement Dates Manufacturer Received: 06/11/2021
• Supplement Dates FDA Received: 11/15/2021
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 07/01/2020
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1
• Patient Outcome(s): Required Intervention
• Patient Age: 64 YR
• Patient Sex: Male
• Patient Weight: 115 KG