MAUDE Adverse Event Report: ENCORE MEDICAL L.P. DISCOVERY ELBOW; DISC ULNA 3X75MM RT W BRNG C

Catalog Number 114813

Device Problems Loose or Intermittent Connection (1371); Appropriate Term/Code Not Available (3191)

Patient Problem No Information (3190)

Event Date 12/11/2019

Event Type  Injury  

Manufacturer Narrative

Additional reporting on this event will be provided as a supplemental report to this document as soon as it becomes available.

Event Description

Revision surgery - ulnar stem came loose, possibly due to a fall or because of patients abnormal anatomy on the ulnar side.

Manufacturer Narrative

The reason for this revision surgery was reported as component loosened.The previous surgery and the surgery detailed in this event occurred 2.3 years apart.The healthcare professional indicated there was an significant adverse event to the patient.There was no delay in surgery and another suitable device was available for use.The revision surgery was completed as intended.The devices were disposed of at hospital and not made available to djo surgical for examination.A review of the implant device history records (dhr) shows that the reported components used in the previous surgery, when released for use, met design and manufacturing requirements.There were no non-conforming material reports (ncmr) associated with the products that may have contributed to the reported event.The devices were within its expiration date at the time of the previous surgery.Customer complaint history of the reported devices showed no present trends or on-going issues that are needing a review.The root cause of this complaint is a revision surgery due to component loosened.There were no findings during this evaluation that indicate the reported devices were defective.No other information was submitted with the complaint regarding pre-existing conditions of the patient or any activities the patient was involved in that may have contributed to the event.There are multiple factors that may contribute to an event that are outside the control of djo surgical.There are no indications of a product or process issue affecting implant safety or effectiveness.

Manufacturer Narrative

D10: adding concomitant part 402438.

• Brand Name: DISCOVERY ELBOW
• Type of Device: DISC ULNA 3X75MM RT W BRNG C
• Manufacturer (Section D): ENCORE MEDICAL L.P.; 9800 metric blvd; austin, tx 78758-5445,
• Manufacturer (Section G): ENCORE MEDICAL L.P.; 9800 metric blvd; austin, tx 78758-5445,
• Manufacturer Contact: teffany hutto ; 9800 metric blvd; austin, tx 78758-5445,
• MDR Report Key: 9564396
• MDR Text Key: 174284986
• Report Number: 1644408-2019-01331
• Device Sequence Number: 1
• Product Code: JDC
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K013042
• 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,Followup
• Report Date: 08/05/2022

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?: No
• Device Operator: Health Professional
• Device Expiration Date: 05/24/2022
• Device Catalogue Number: 114813
• Device Lot Number: 455460
• Was Device Available for Evaluation?: No
• Initial Date Manufacturer Received: 12/11/2019
• Initial Date FDA Received: 01/08/2020
• Supplement Dates Manufacturer Received: 02/07/2020; 02/07/2020
• Supplement Dates FDA Received: 03/06/2020; 08/05/2022
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• 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: 114700 LOT 688620; 402438 COBALT MV BONE CEMENT 40GM B
• Patient Outcome(s): Required Intervention; Other
• Patient Age: 58 YR
• Patient Sex: Male