MAUDE Adverse Event Report: MICROPORT ORTHOPEDICS INC. EVOLUTIONMP TIB SCREWLESS BF SIZE 6 STANDARD RIGH; KNEE COMPONENT

Model Number ETPLB6SR

Device Problem Break (1069)

Patient Problem Insufficient Information (4580)

Event Type  Injury  

Manufacturer Narrative

This event will be updated once the investigation is complete.Trends will be evaluated.

Event Description

Allegedly, patient was revised due to fractured base plate.Components not revised: part id: efsrp6pr product name: evolution®mp fem cs/cr porous; part id: kpon32mb product name: advance® onlay metal back patella 32mm.

• Brand Name: EVOLUTIONMP TIB SCREWLESS BF SIZE 6 STANDARD RIGH
• Type of Device: KNEE COMPONENT
• Manufacturer (Section D): MICROPORT ORTHOPEDICS INC.; 5677 airline rd.; arlington TN 38002
• Manufacturer (Section G): MICROPORT ORTHOPEDICS INC.; 5677 airline rd.; arlington TN 38002
• Manufacturer Contact: 5677 airline road; arlington, TN 38002 ; 9018674771
• MDR Report Key: 12158542
• MDR Text Key: 261430315
• Report Number: 3010536692-2021-00379
• Device Sequence Number: 1
• Product Code: MBH
• UDI-Device Identifier: M684ETPLB6SR1
• UDI-Public: M684ETPLB6SR1
• Combination Product (y/n): N
• Reporter Country Code: US
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative
• Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial,Followup
• Report Date: 10/20/2021

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: Other
• Device Model Number: ETPLB6SR
• Device Catalogue Number: ETPLB6SR
• Device Lot Number: 1801828
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 06/22/2021
• Initial Date Manufacturer Received: 06/22/2021
• Initial Date FDA Received: 07/13/2021
• Supplement Dates Manufacturer Received: 06/22/2021
• Supplement Dates FDA Received: 10/20/2021
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Is the Device Single Use?: Yes
• Type of Device Usage: N
• Patient Sequence Number: 1
• Patient Outcome(s): Required Intervention