MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS, INC. 1818910 SIGMA HP UNI TIB TRAY SZ3 LMRL; EARLY INTERVENTION : KNEE TIBIAL TRAY

Catalog Number 102451300

Device Problems Malposition of Device (2616); Unintended Movement (3026)

Patient Problems Bone Fracture(s) (1870); No Code Available (3191)

Event Date 01/25/2016

Event Type  Injury  

Manufacturer Narrative

Product complaint : (b)(4).Initial reporter occupation: lawyer.(b)(4).If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.

Event Description

The patient underwent a left knee revision due to a medial tibial condyle fracture with tibial tray subsidence and malpositioning.The surgeon noted there was no loosening.Depuy cement was used during the primary operation.Doi: (b)(6) 2016.Dor: 8/1/2016 left knee.

Manufacturer Narrative

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.Product complaint # (b)(4).Investigation summary : no device associated with this report was received for examination.Depuy synthes considers the investigation closed.Should additional information be received, the information will be reviewed and the investigation may be re-opened as necessary.Device history lot : null.Device history batch : null.Device history review : null.If information is obtained that was not available for the initial medwatch, a follow-up medwatch, a follow-up medwatch will be filed as appropriate.

• Brand Name: SIGMA HP UNI TIB TRAY SZ3 LMRL
• Type of Device: EARLY INTERVENTION : KNEE TIBIAL TRAY
• Manufacturer (Section D): DEPUY ORTHOPAEDICS, INC. 1818910; 700 orthopaedic drive; warsaw IN 46582 0988
• MDR Report Key: 8929954
• MDR Text Key: 155485640
• Report Number: 1818910-2019-102136
• Device Sequence Number: 1
• Product Code: HRY
• UDI-Device Identifier: 10603295002338
• UDI-Public: 10603295002338
• Combination Product (y/n): N
• PMA/PMN Number: K070267
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: other
• Type of Report: Initial,Followup
• Report Date: 08/05/2019

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?: Yes
• Device Operator: Health Professional
• Device Catalogue Number: 102451300
• Device Lot Number: 717262
• Was Device Available for Evaluation?: No
• Initial Date Manufacturer Received: 08/05/2019
• Initial Date FDA Received: 08/26/2019
• Supplement Dates Manufacturer Received: 10/01/2019
• Supplement Dates FDA Received: 10/01/2019
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1
• Treatment: SIGMA HP UNI FEMORAL SZ3 LM/RL; SIGMA HP UNI INS SZ3 7MM LM/RL; SMARTSET GMV 40G US EO; SIGMA HP UNI FEMORAL SZ3 LM/RL; SIGMA HP UNI INS SZ3 7MM LM/RL; SMARTSET GMV 40G US EO
• Patient Outcome(s): Required Intervention
• Patient Age: 68 YR