MAUDE Adverse Event Report: DEPUY CMW - 9610921 SMARTSET GMV 40G US EO; BONE CEMENT : BONE CEMENT

Model Number 5450-50-501

Device Problem Loss of or Failure to Bond (1068)

Patient Problem Pain (1994)

Event Date 04/25/2022

Event Type  Injury  

Event Description

(b)(4) medical records ad 6 sep 2022.Pdf, were reviewed by clinician.Left knee doi: (b)(6) 2021.On (b)(6) 2022, the patient had a right knee revision to address right total knee aseptic loosening proximal tibial fracture.The femoral component was well fixed and required an osteotomy for better access, which was then repaired.Tibial tray was noted to be loose at the implant to cement interface.During the removal of the tibial tray, a split was noticed at the proximal tibia (fracture).The surgeon reported that it was unknown if the fracture was there previously.A guide wire was used to for compression of the bone fracture.Competitor components were implanted during this procedure.Doi: 2021.Dor: (b)(6) 2022 right knee.

Manufacturer Narrative

Product complaint # (b)(4).Initial reporter occupation: lawyer.Dmf# - 13704.Trade name gentamicin sulphate.Active ingredient(s) gentamicin sulphate.Dosage form - powder.Strength 1.0g active in our cements.Depuy synthes is submitting this report pursuant to the provisions of 21 cfr, part 803.This report may be based on information which depuy synthes has not been able to investigate or verify prior to the required reporting date.This report does not reflect a conclusion by fda, depuy synthes or its employees that the report constitutes an admission that the device, depuy synthes, or its employees caused or contributed to the potential event described in this report.If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.

Manufacturer Narrative

Product complaint # (b)(4).Investigation summary no device associated with this report was received for examination.The information received will be retained for potential series investigations if triggered by trend analysis, post market surveillance, or other events within the quality system.Depuy considers the investigation closed.Should additional information be received, the information will be reviewed and the investigation will be re-opened as necessary.Device history lot the product investigation found no evidence suspecting an error in the manufacturing or material that would be a contributing factor in the reported allegation(s).A manufacturing records evaluation (mre) was not performed.

• Brand Name: SMARTSET GMV 40G US EO
• Type of Device: BONE CEMENT : BONE CEMENT
• Manufacturer (Section D): DEPUY CMW - 9610921; cornford rd.; blackpool IN FY4 4 QQ; UK FY4 4QQ
• Manufacturer (Section G): DEPUY CMW - 9610921; cornford rd; blackpool FY4 4 QQ; UK FY4 4QQ
• Manufacturer Contact: kate karberg ; 700 orthopaedic dr.; warsaw, IN 46581-0988 ; 3035526892
• MDR Report Key: 15804267
• MDR Text Key: 303712236
• Report Number: 1818910-2022-23023
• Device Sequence Number: 1
• Product Code: MBB
• UDI-Device Identifier: 10603295174295
• UDI-Public: 10603295174295
• Combination Product (y/n): Y
• Reporter Country Code: US
• PMA/PMN Number: K081163
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Other
• Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date: 11/16/2022

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 11/16/2022
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Expiration Date: 01/31/2022
• Device Model Number: 5450-50-501
• Device Catalogue Number: 545050501
• Device Lot Number: 9439737
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Date Manufacturer Received: 11/18/2022
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Date Device Manufactured: 02/13/2020
• 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
• Treatment: ATTUNE MEDIAL DOME PAT 35MM.; ATTUNE PS FEM RT SZ 7 CEM.; ATTUNE PS RP INSRT SZ7 5MM.; ATTUNE RP TIB BASE SZ 7 CEM.; ATTUNE SOLO PINNING SYSTEM.; SMARTMIX CTS BOWL EMPTY.; SMARTSET GMV 40G US EO.; SMARTSET GMV 40G US EO.; SMARTSET GMV 40G US EO.
• Patient Outcome(s): Required Intervention
• Patient Age: 74 YR
• Patient Sex: Male