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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: MEDACTA INTERNATIONAL SA GMK-SPHERE TIBIAL INSERT FIXED SPHERE FLEX SIYE 4/12 MM L; KNEE TIBIAL INSERT
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MEDACTA INTERNATIONAL SA GMK-SPHERE TIBIAL INSERT FIXED SPHERE FLEX SIYE 4/12 MM L; KNEE TIBIAL INSERT Back to Search Results
Model Number 02.12.0412FL
Health Effect - Clinical Code Tissue Breakdown (2681)
Date of Event 05/28/2021
Type of Reportable Event Serious Injury
Additional Manufacturer Narrative
Batch review performed on 09 june 2021: lot 1910170: (b)(4) items manufactured and released on 2-jan-2020.Expiration date: 2024-12-09.No anomalies found related to the problem.To date, (b)(4) items of the same lot have been already sold without any similar reported event.
 
Event or Problem Description
23 days after the primary surgery the patient came in reporting pain due to sustaining a quadriceps strain.The cause of the development of the quadriceps strain is unknown.The surgeon sutured the patient's quadriceps and revised the poly.The surgery was completed successfully.
 
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Brand Name
GMK-SPHERE TIBIAL INSERT FIXED SPHERE FLEX SIYE 4/12 MM L
Common Device Name
KNEE TIBIAL INSERT
Manufacturer (Section D)
MEDACTA INTERNATIONAL SA
strada regina
castel san pietro, 6874
SZ  6874
MDR Report Key12038960
Report Number3005180920-2021-00522
Device Sequence Number14454022
Product Code JWH
UDI-Device Identifier07630030826573
UDI-Public07630030826573
Combination Product (Y/N)N
Initial Reporter CountryUS
PMA/510(K) Number
K121416
Number of Events Summarized1
Summary Report (Y/N)N
Device Implanted Year2021
Device Explanted Year2021
Serviced by Third Party (Y/N)N
Reporter Type Manufacturer
Report Source other
Initial Reporter Occupation Non-Healthcare Professional
Type of Report Initial
Report Date (Section B) 06/22/2021
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 Model Number02.12.0412FL
Device Catalogue Number02.12.0412FL
Device Lot Number1910170
Was Device Available for Evaluation? No
Type of Report(Section G)Thirty-Day
Initial Date Received by Manufacturer 05/28/2021
Initial Report FDA Received Date06/22/2021
Is This a Single-Use Device that was
Reprocessed and Reused on a Patient? (Y/N)		 No
Patient Sequence Number1
Outcome Attributed to Adverse Event Required Intervention;
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