MAUDE Adverse Event Report: ENCORE MEDICAL L.P EMPOWR POROUS KNEE; DJO EMPOWR KNEETM, PRESS FIT BP MINUS, 5R

Model Number	353-04-105
Health Effect - Clinical Code	Fall (1848)
Date of Event	02/03/2021
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Additional reporting on this event will be provided as a supplemental report to this document if it becomes available.
Event or Problem Description
Revision surgery - the patient fell, after a recent surgery.Tibia went into varus.Revised the press fit tibia with a universal tibia, cemented stem, and thicker poly.
Additional Manufacturer Narrative
Manufacturer narrative: the reason for this revision surgery was reported as patient fell, tibia went into varus.The previous surgery and the surgery detailed in this event occurred 3 months and 3 weeks apart.The healthcare professional indicated 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 device history records (dhr) show that the reported components used in the previous surgery, when released for use, met design and manufacturing requirements.There was an ncmr-54172 associated with the main part #353-04-105, djo empowr kneetm, press fit bp minus, 5r which documents that out of 10 parts lot all parts were rejected due to burrs on the slot.Later the rejected parts were reworked and accepted after proper justification.The devices were verified to have gone through an acceptable sterilization process and 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 was a revision surgery due to patient fell, tibia went into varus.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.Agent has clearly mentioned that "patient fell" and there are multiple factors that may also contribute to an event that are outside the control of djo surgical such as poor bone density, patient bone deterioration, patient activities or trauma.There are no indications of a product or process issue affecting implant safety or effectiveness.Additional reporting on this event will be provided as a supplemental report to this document if it becomes available.
Additional Manufacturer Narrative
Corrected data: d.10.Concomitant medical products.Initial mdr reported: 342-14-705 lot 139t1027.243-02-105 lot 284w1045.Only 342-14-705 lot 139t1027 should have been reported.Additional reporting on this event will be provided as a supplemental report to this document if it becomes available.

• Brand Name: EMPOWR POROUS KNEE
• Common Device Name: DJO EMPOWR KNEETM, PRESS FIT BP MINUS, 5R
• 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: kierstan soderman ; 9800 metric blvd.; austin, tx 78758-5445
• MDR Report Key: 11404567
• Report Number: 1644408-2021-00121
• Device Sequence Number: 3372132
• Product Code: MBH
• UDI-Device Identifier: 00190446230335
• UDI-Public: (01)00190446230335
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K171991
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2020
• Device Explanted Year: 2021
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 11/12/2021

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
• Operator of Device: Health Professional
• Device Expiration Date: 03/06/2026
• Device Model Number: 353-04-105
• Device Catalogue Number: 353-04-105
• Device Lot Number: 220W1025
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 02/03/2021
• Supplement Date Received by Manufacturer: 04/08/2021; 05/27/2021
• Initial Report FDA Received Date: 03/03/2021
• Supplement Report FDA Received Date: 05/04/2021; 11/12/2021
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 03/17/2020
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: 243-02-105 LOT 284W1045; 342-14-705 LOT 139T1027; 342-14-705, LOT 139T1027; 243-02-105 LOT 284W1045; 342-14-705 LOT 139T1027
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 79 YR
• Patient Sex: Female