MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS INC US MBT REVISION CEM TIB TRAY SZ 2; MBT TIBIAL TRAY : KNEE TIBIAL TRAY

Model Number	1294-35-120
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Pain (1994); Sepsis (2067)
Date of Event	01/01/2021
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
(b)(4).
Event or Problem Description
Revision of total left knee replacement on sepsis and loosening.Fracture / loosening of the femoral bolt screw.Consequence on the patient: pain +++, no debris, displacement of the femur.Doi: (b)(6) 2019, dor: unknown, left knee.
Additional Manufacturer Narrative
Product complaint # (b)(4).Investigation summary: no device associated with this report was received for examination.All available x-rays and photographs were reviewed, and the investigation could not draw any conclusions about the reported event without the device to examine.Depuy synthes considers the investigation closed at this time.Should additional information be received, the information will be reviewed, and the investigation may 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: MBT REVISION CEM TIB TRAY SZ 2
• Common Device Name: MBT TIBIAL TRAY : KNEE TIBIAL TRAY
• Manufacturer (Section D): DEPUY ORTHOPAEDICS INC US; 700 orthopaedic drive; warsaw IN 46581 0988
• MDR Report Key: 12357963
• Report Number: 1818910-2021-18395
• Device Sequence Number: 11710821
• Product Code: NJL
• UDI-Device Identifier: 10603295025948
• UDI-Public: 10603295025948
• Combination Product (Y/N): N
• Initial Reporter Country: FR
• PMA/510(K) Number: P830055
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2019
• 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
• Report Date (Section B): 07/30/2021

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: 1294-35-120
• Device Catalogue Number: 129435120
• Device Lot Number: HY6566
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 07/30/2021
• Supplement Date Received by Manufacturer: 10/12/2021
• Initial Report FDA Received Date: 08/24/2021
• Supplement Report FDA Received Date: 10/21/2021
• 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: MBT REVISION CEM TIB TRAY SZ 2.; MBT TRAY SLEEVE POR M/L 29MM.; P.F.C.* FLUT TIB ROD 75X16MM.; P.F.C.* FLUT TIB ROD 75X18MM.; PFC*SIGMA TC3 FEM LEFT SZ3.; PFC*SIGMA/OV/DOME PAT 3PEG,41.; SIG FEM ADAP +2/-2 OFFSET BOLT.; SIG FEM ADAP +2/-2 OFFSET BOLT.; SIGMA FEM ADAPTER 5 DEGREE.; SIGMA FEM ADAPTER 5 DEGREE.; TC3 RP TIBIAL INSERT S3,22.5.; UNIVERSAL FEM SLV DIS POR 34MM.; MBT REVISION CEM TIB TRAY SZ 2; MBT TRAY SLEEVE POR M/L 29MM; P.F.C.* FLUT TIB ROD 75X16MM; P.F.C.* FLUT TIB ROD 75X18MM; PFC*SIGMA TC3 FEM LEFT SZ3; PFC*SIGMA/OV/DOME PAT 3PEG,41; SIG FEM ADAP +2/-2 OFFSET BOLT; SIG FEM ADAP +2/-2 OFFSET BOLT; SIGMA FEM ADAPTER 5 DEGREE; SIGMA FEM ADAPTER 5 DEGREE; TC3 RP TIBIAL INSERT S3,22.5; UNIVERSAL FEM SLV DIS POR 34MM
• Outcome Attributed to Adverse Event: Required Intervention