MAUDE Adverse Event Report: AESCULAP AG AS VEGA PS TIBIAL PLATEAU CEMENTED T1; KNEE ENDOPROSTHETICS

Model Number	NX051Z
Medical Device Problem Codes	Patient Device Interaction Problem (4001); Loosening of Implant Not Related to Bone-Ingrowth (4002)
Health Effect - Clinical Code	Implant Pain (4561)
Date of Event	07/20/2018
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Investigation results: as of the date of this report the complaint product was not provided for investigation.Therefore, a thorough investigation is not possible.The device quality and manufacturing history records (dhr) have been checked for all available lot numbers and the products found to be according to our specification valid at the time of production.One further incident has been filed with the same lot regarding implant loosening until today.A clear root cause conclusion cannot be drawn due to the non-availability of important information and the device itself.The conclusion from the root cause analysis is that a systematic device deviation is unlikely, since the received complaints are limited to certain health care institutions and their applicants.The participation of the applicants in this deviation scenario cannot be excluded by today.Based on the root cause analysis result no corrective actions have been carried out.As a preventive action we were in contact with the affected health care institutions and applicants in order to reduce the probability of recurrence.The complaints were submitted to aesculap ag as a summary report.In order to examine further actions, all cases from the summary report are processed as vigilance suspicion cases and are continuously monitored.
Event or Problem Description
It was reported that there was an issue with nx051z - as vega ps tibial plateau cemented t1.It was reported that as a result of having the product implanted, the patient has experienced loosening of the implant which resulted in a revision surgery.The primary surgery occurred on (b)(6) 2015 and the revision surgery occurred on (b)(6) 2017.All available information has been provided at this time; if additional information becomes available the complaint will be updated accordingly.The adverse event is filed under aag reference (b)(4).Involved components: nx009z (ps femur cemented f4n lt), nx043 (universal patella p3), nx110 (ps pe insert t1/t1+, 10mm), nn260p (peek plug f/ tibia).

• Brand Name: AS VEGA PS TIBIAL PLATEAU CEMENTED T1
• Common Device Name: KNEE ENDOPROSTHETICS
• Manufacturer (Section D): AESCULAP AG; po box 40; tuttlingen, 78501 ; GM 78501
• MDR Report Key: 11517399
• Report Number: 9610612-2020-00370
• Device Sequence Number: 3678756
• Product Code: JWH
• UDI-Device Identifier: 04046963810375
• UDI-Public: 4046963810375
• Combination Product (Y/N): N
• Initial Reporter State: FL
• Initial Reporter Country: US
• PMA/510(K) Number: K101281
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2015
• Device Explanted Year: 2017
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 03/18/2021

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?: Yes
• Operator of Device: Health Professional
• Device Expiration Date: 12/31/2024
• Device Model Number: NX051Z
• Device Catalogue Number: NX051Z
• Device Lot Number: 52106248
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 07/20/2018
• Initial Report FDA Received Date: 03/18/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention