MAUDE Adverse Event Report: AESCULAP AG AS NUT F/FEMUR EXTENS.STEM ALL SZ.NEUTR.; KNEE ENDOPROSTHESES

Model Number NR400Z

Device Problems Product Quality Problem (1506); Defective Device (2588); Device Contaminated During Manufacture or Shipping (2969)

Patient Problem Foreign Body Reaction (1868)

Event Date 02/19/2019

Event Type  Injury  

Manufacturer Narrative

(b)(4).Implant date: unknown.When additional information is received a follow up report will be submitted.

Event Description

It was reported by the healthcare professional "patient had an enduro implanted, presented with joint pain and stiffness, was examined in clinic and determine an exploratory washout was necessary.Intraoperative tissue samples were collected and sent for lab work - tissues had a blackened appearance.The underside of the patellar tendon and intercondylar box had the highest concentration of blackened tissue.No damage to any of the components was observed neither were there indications of loosening of the hinge mechanism.A thorough washout was performed and the wound closed.Surgeon awaiting lab results to determine treatment.Images from case are available." this incident did not cause or contribute to serious injury or death or a delay in surgery.All medwatch submissions related are: 9610612-2019-00178.

Manufacturer Narrative

Additional information: patient information, description, tests, common device name, model #, lot #, expiration date, implant date, manufacture date.Manufacturing site evaluation: devices are not available because the components are still implanted.No pictures were provided; surgical specimen and final results provided.We do not know the consistency and origin of the mentioned tissue with blackened appearance.Batch history review - the device quality and manufacturing history records have been checked for all available lot numbers and found to be according to our specifications valid at the time of production.Conclusion and root cause - based on the information available, it is not possible to determine a possible root cause for the failure.At this time we assume that the failure is not product related.It could be possible that the failure is usage/patient related.Rationale - in light of the incomplete information received about the lab results, and due to the circumstance that we did not receive the complained devices for investigation, it is not possible to determine a root cause for the mentioned failure.There are no hints for a material problem.According to the quality standard and files a material defect and production error is improbable.At this time we exclude a design-related error because the market feedback is unremarkable on this matter.A maintenance failure also can be excluded because this issue is only relevant for instruments.It could be possible that due to so-called "third-body wear" (such wear includes foreign particles for example bone cement, bone, or metal particles) in the knee mechanism (bush bearing) lead to a peek abrasion which could lead potentially to the mentioned blackened tissue.A capa is not necessary.

Event Description

Clarification was received: it was reported that a patient was initially implanted with enduro knee products in the right knee on (b)(6)2018.On (b)(6)2019, the patient underwent an arthrotomy of the knee and quadriceps-plasty.Tissue specimens were taken.Results showed benign tissue, microscopically examined, demonstrating patchy calcification; no definitive evidence of malignancy.No additional patient harm or intervention has been reported since the surgery.Associated components (reported separately): as enduro menical component, as femur extension stem, as tibial offset stem, as enduro tibial component offset, as enduro femoral component.

• Brand Name: AS NUT F/FEMUR EXTENS.STEM ALL SZ.NEUTR.
• Type of Device: KNEE ENDOPROSTHESES
• Manufacturer (Section D): AESCULAP AG; po box 40; tuttlingen, 78501 ; GM 78501
• MDR Report Key: 8434525
• MDR Text Key: 139290210
• Report Number: 9610612-2019-00179
• Device Sequence Number: 1
• Product Code: KRO
• Combination Product (y/n): N
• PMA/PMN Number: K101815
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: distributor
• Type of Report: Initial,Followup
• Report Date: 05/29/2019

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 03/19/2019
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: NR400Z
• Device Catalogue Number: NR400Z
• Device Lot Number: 52410928
• Was Device Available for Evaluation?: No
• Distributor Facility Aware Date: 04/29/2019
• Date Manufacturer Received: 04/29/2019
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1
• Patient Outcome(s): Required Intervention
• Patient Age: 74 YR