MAUDE Adverse Event Report: MICROPORT ORTHOPEDICS INC. ADVANCE II MEDIAL PIVOT TIBIAL INSERT SZ 4 LEFT 1; KNEE COMPONENT

Model Number	KIMP414L
Health Effect - Clinical Code	Loss of Range of Motion (2032)
Type of Reportable Event	Serious Injury
Event or Problem Description
Allegedly, patient was revised due to tightness in flexion.The 14mm insert was explanted and a 12mm insert was implanted.(b)(6).

• Brand Name: ADVANCE II MEDIAL PIVOT TIBIAL INSERT SZ 4 LEFT 1
• Common Device Name: KNEE COMPONENT
• Manufacturer (Section D): MICROPORT ORTHOPEDICS INC.; 5677 airline rd.; arlington TN 38002
• MDR Report Key: 10311760
• Report Number: 3010536692-2020-00496
• Device Sequence Number: 3623649
• Product Code: JWH
• UDI-Device Identifier: M684KIMP414L1
• UDI-Public: M684KIMP414L1
• Combination Product (Y/N): N
• Initial Reporter Country: AU
• PMA/510(K) Number: K972770
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2017
• Device Explanted Year: 2020
• Reporter Type: Manufacturer
• Report Source: foreign
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 07/22/2020

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
• Operator of Device: Health Professional
• Device Model Number: KIMP414L
• Device Catalogue Number: KIMP414L
• Device Lot Number: 0311320831
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 06/29/2020
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 06/29/2020
• Initial Report FDA Received Date: 07/22/2020
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 59 YR