MAUDE Adverse Event Report: ENCORE MEDICAL L. P. EMPOWR POROUS KNEE SYSTEM; DJO EMPOWR KNEETM, PRESS FIT BP MINUS, 9L

Model Number	353-03-109
Health Effect - Clinical Code	Insufficient Information (4580)
Date of Event	03/17/2021
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Additional reporting on this event will be provided as a supplemental report to this document as soon as it becomes available.
Event or Problem Description
Revision surgery - due to dr.Revised the left total knee because the patient was complaining.
Event or Problem Description
Revision surgery - surgeon revised the left total knee because the patient was complaining of pain.
Additional Manufacturer Narrative
Manufacturer narrative: the reason for this revision surgery was reported as pain.The previous surgery and the surgery detailed in this event occurred 8 months and 2 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 a nonconformance associated with the main part #353-03-109 djo empowr kneetm, press fit bp minus, 9l which documents that out of 10 parts lot, 2 parts were rejected and scrapped due to dimension out of tolerance.All other items in the lot were met with fit, form and function requirements.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 pain.There were no findings during this evaluation that indicate the reported devices were defective.No information was submitted with the complaint regarding preexisting conditions of the patient or any activities the patient was involved in that may have contributed to the event.There are multiple factors that may also contribute to an event that are outside the control of djo surgical such as poor bone density, inadequate soft tissue support, 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 as soon as it becomes available.

• Brand Name: EMPOWR POROUS KNEE SYSTEM
• Common Device Name: DJO EMPOWR KNEETM, PRESS FIT BP MINUS, 9L
• Manufacturer (Section D): ENCORE MEDICAL L. P.; 9800 metric blvd.; austin TX 78758 5445
• MDR Report Key: 11672083
• Report Number: 1644408-2021-00309
• Device Sequence Number: 19622132
• Product Code: MBH
• UDI-Device Identifier: 00190446230274
• UDI-Public: (01)00190446230274
• Combination Product (Y/N): N
• Initial Reporter State: AL
• 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): N
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 05/28/2021

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: 09/05/2025
• Device Model Number: 353-03-109
• Device Catalogue Number: 353-03-109
• Device Lot Number: 214W1012
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 03/17/2021
• Supplement Date Received by Manufacturer: 05/03/2021
• Initial Report FDA Received Date: 04/15/2021
• Supplement Report FDA Received Date: 05/28/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: 341-10-709, LOT 069T1070; 341-10-709, LOT 069T1070
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 68 YR