MAUDE Adverse Event Report: MICROPORT ORTHOPEDICS INC. ADVANCE II MEDIAL PIVOT TIBIAL INSERT SZ 2 LEFT 1; KNEE COMPONENT

Model Number	KIMP210L
Type of Reportable Event	Serious Injury
Event or Problem Description
Allegedly, patient was revised due to infection.Revision njr number: (b)(4).Side: l.Primary asa: mild disease not incapacitating.Mhra reference no: (b)(4).

• Brand Name: ADVANCE II MEDIAL PIVOT TIBIAL INSERT SZ 2 LEFT 1
• Common Device Name: KNEE COMPONENT
• Manufacturer (Section D): MICROPORT ORTHOPEDICS INC.; 5677 airline rd.; arlington TN 38002
• MDR Report Key: 11404638
• Report Number: 3010536692-2021-00138
• Device Sequence Number: 17285148
• Product Code: JWH
• UDI-Device Identifier: M684KIMP210L1
• UDI-Public: M684KIMP210L1
• Combination Product (Y/N): N
• Initial Reporter Country: UK
• PMA/510(K) Number: K972770
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2011
• Device Explanted Year: 2020
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 03/03/2021

1 Device 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: KIMP210L
• Device Catalogue Number: KIMP210L
• Device Lot Number: 0111292778
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 02/22/2021
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 02/22/2021
• Initial Report FDA Received Date: 03/03/2021