MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS INC US LPS PROX TIB REPLC COMP XSM; LPS AND S-ROM : KNEE TIBIAL TRAY

Model Number 1987-21-105

Device Problems Device Dislodged or Dislocated (2923); Naturally Worn (2988)

Patient Problem Inflammation (1932)

Event Date 06/30/2022

Event Type  Injury  

Manufacturer Narrative

Product complaint # (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

Patient¿s previous proximal tibia replacement (2020), continuing to dislocate poly out of prox tibia component.Revision surgery demonstrated prox tibia replacement component was rotated, causing poly insert to dislocate from post.Also when removed, evidence of metal charring in the implant noted, which can lead to metalosis of components/tissue.Was surgery delayed due to the reported event? no.Action taken when event occurred? replaced proximal tibia component, added segmental 25mm component.Was procedure successfully completed? yes.Were fragments generated? yes.If yes, were they removed easily without additional intervention? unknown.Other information: metal wear noted.Patient status/ outcome / consequences? yes.Patient consequence description/was there a clinical outcome experienced by the patient (infection, inflammation, etc.)? inflammation, dislocations.Was other medical intervention (e.G.X-rays, additional procedures, prescriptions, otc, revision) required: unknown.If yes, describe: rotation of component in segmental sleeve caused repeated poly insert dislocations and potential metal breakdown.Is the patient part of a clinical study? unknown.(b)(6).Device property of: none.Device in possession of: none.By checking this box i certify that all information that are known/available has been disclosed.If any new information will be made available, the additional information will be submitted through cst.True.

Manufacturer Narrative

Product complaint #(b)(4).This report is being submitted pursuant to the provisions of 21 cfr, part 803.This report may be based on information which has not been investigated or verified prior to the required reporting date.This report does not reflect a conclusion by depuy synthes joint reconstruction, or its employees that the report constitutes an admission that the product, depuy synthes joint reconstruction, 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 report, a follow-up report will be filed as appropriate.

Manufacturer Narrative

Product complaint # (b)(4).Investigation summary : the device associated with this complaint was received for examination.The photo investigation and examination of the device found evidence of damage/wear which confirmed the reported allegation.Depuy synthes considers the investigation closed at this time.Should additional information be received, the information will be reviewed and the investigation may be re-opened as necessary.Device history lot : a search of the depuy nonconformance (nc) quality system found no nc¿s associated with this product/lot combination.Based on the inability to find any nc¿s against the provided product code/lot code combination, it is reasonable to conclude that there are no anomalies with regard to manufacturing or inspection contained in the device history records that would contribute to the reported event.

• Brand Name: LPS PROX TIB REPLC COMP XSM
• Type of Device: LPS AND S-ROM : KNEE TIBIAL TRAY
• Manufacturer (Section D): DEPUY ORTHOPAEDICS INC US; 700 orthopaedic drive; warsaw IN 46581 0988
• Manufacturer (Section G): DEPUY ORTHOPAEDICS, INC. 1818910; 700 orthopaedic dr.; warsaw IN 46581 0988
• Manufacturer Contact: kate karberg ; 700 orthpaedic dr.; warsaw, IN 46581 ; 3035526892
• MDR Report Key: 15054835
• MDR Text Key: 296162214
• Report Number: 1818910-2022-13431
• Device Sequence Number: 1
• Product Code: KRO
• UDI-Device Identifier: 10603295079071
• UDI-Public: 10603295079071
• Combination Product (y/n): N
• Reporter Country Code: CA
• PMA/PMN Number: K062301
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Foreign,Health Professional,Company Representative
• Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup,Followup
• Report Date: 07/19/2022

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 Model Number: 1987-21-105
• Device Catalogue Number: 198721105
• Device Lot Number: C71247
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Initial Date Manufacturer Received: 07/01/2022
• Initial Date FDA Received: 07/19/2022
• Supplement Dates Manufacturer Received: 09/20/2022; 09/28/2022
• Supplement Dates FDA Received: 09/24/2022; 09/29/2022
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 05/03/2018
• 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: HINGED PIN; UNK KNEE STEM LPS; UNK KNEE TIBIAL INSERT LPS
• Patient Outcome(s): Required Intervention
• Patient Age: 20 YR
• Patient Sex: Male