MAUDE Adverse Event Report: MICROPORT ORTHOPEDICS INC. ADVANCE II MEDIAL PIVOT TIBIAL INSERT SZ 5 LEFT 1; KNEE COMPONENT

Model Number KIMP514L

Device Problem Adverse Event Without Identified Device or Use Problem (2993)

Patient Problem Not Applicable (3189)

Event Type  Injury  

Event Description

Allegedly, patella resurfacing and poly swap , same thickness poly was put back in.Left knee components not revised: advance® primary femoral size 5 left porous product id : kftcpc5l lot number: 01333763, advance® ii spiked tibial base porous coated size 5+ product id: ktsppc51 lot number : 09227685, advance® modular keel sz 5/6 product id: spkt0024 lot number: 01334085.

• Brand Name: ADVANCE II MEDIAL PIVOT TIBIAL INSERT SZ 5 LEFT 1
• 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: 10851708
• MDR Text Key: 216610470
• Report Number: 3010536692-2020-00698
• Device Sequence Number: 1
• Product Code: JWH
• UDI-Device Identifier: M684KIMP514L1
• UDI-Public: M684KIMP514L1
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K972770
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: distributor
• Reporter Occupation: Physician
• Type of Report: Initial
• Report Date: 11/17/2020

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
• Device Operator: Health Professional
• Device Model Number: KIMP514L
• Device Catalogue Number: KIMP514L
• Device Lot Number: 120A132553
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 11/03/2020
• Initial Date Manufacturer Received: 11/03/2020
• Initial Date FDA Received: 11/17/2020
• 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): Other