MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS INC US LPS FEM TO SLEEVE ADAPTER +0; LPS AND S-ROM : KNEE FEMORAL ACCESSORY

Model Number	1987-06-000
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Fall (1848); Pain (1994); Limb Fracture (4518)
Date of Event	06/15/2021
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Product complaint #: (b)(4).If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.
Event or Problem Description
Patient underwent a complex primary tkr on the (b)(6) 2019 following a motor vehicle accident - she received a lps distal femoral replacement with mbt revision tibia.She had a fall a week ago and sustained a periprosthetic fracture of the femur and required revision surgery.The tibial components from the primary surgery were well fixed and left in place, the femoral components were removed and replaced with new components.There was a fracture of the press fit stem at the junction of the stem/sleeve as a result of the fall.The retrieved components were sent to the bio engineering department at royal perth hospital for evaluation as per standard retrieval policy here in wa (not available for return).There were no fragments generated as a result of the breakage and all parts were retrieved.
Additional Manufacturer Narrative
Product complaint # (b)(4).This report is being submitted pursuant to the provisions of 21 cfr, part 803.This report may be based on information which has not been investigated or verified prior to the required reporting date.This report does not reflect a conclusion by depuy synthes joint reconstruction, or its employees that the report constitutes an admission that the product, depuy synthes joint reconstruction, or its employees caused or contributed to the potential event described in this report.If information is obtained that was not available for the initial report, a follow-up report will be filed as appropriate.
Event or Problem Description
Additional information received stated that there was no extension to the surgical time.
Additional Manufacturer Narrative
Product complaint # (b)(4).Investigation summary : no device associated with this report was received for examination.The information received will be retained for potential series investigations if triggered by trend analysis, post market surveillance, or other events within the quality system.Depuy considers the investigation closed.Should additional information be received, the information will be reviewed and the investigation will be re-opened as necessary.Device history lot : the product investigation found no evidence suspecting an error in the manufacturing or material that would be a contributing factor in the reported allegation(s).A manufacturing records evaluation (mre) was not performed.

• Brand Name: LPS FEM TO SLEEVE ADAPTER +0
• Common Device Name: LPS AND S-ROM : KNEE FEMORAL ACCESSORY
• Manufacturer (Section D): DEPUY ORTHOPAEDICS INC US; 700 orthopaedic drive; warsaw IN 46581 0988
• MDR Report Key: 12131399
• Report Number: 1818910-2021-14209
• Device Sequence Number: 11630179
• Product Code: JWH
• UDI-Device Identifier: 10603295078487
• UDI-Public: 10603295078487
• Combination Product (Y/N): N
• Initial Reporter Country: AS
• PMA/510(K) Number: K071417
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2019
• Device Explanted Year: 2021
• 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,Followup,Followup
• Report Date (Section B): 06/15/2021

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 Number: 1987-06-000
• Device Catalogue Number: 198706000
• Device Lot Number: 349278
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 06/15/2021
• Supplement Date Received by Manufacturer: 07/22/2021; 08/12/2021
• Initial Report FDA Received Date: 07/07/2021
• Supplement Report FDA Received Date: 07/27/2021; 08/16/2021
• 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: LPS DISTAL FEM COMP XXSM RT; LPS UNIV TIB HIN INS XXSM 23MM; UNIVERSAL FEM SLV FUL POR 31MM; UNIVERSAL STEM 75X10MM FLUTED
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 59 YR