MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS INC US SIGMA PS CEM FEM SZ3 L; SIGMA KNEE PRIMARY : KNEE FEMORAL

Model Number	1960-40-300
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Muscular Rigidity (1968); Loss of Range of Motion (2032)
Date of Event	08/09/2021
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 was revised due to stiffness.Patient was only able to extend her knee approximately seventy degrees, according to the surgeon who performed this patient's primary and revision procedure.The patient's primary sigma components were removed and replaced by attune revision components.Doi: (b)(6) 2008.Dor: (b)(6) 2021.Left knee.
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.
Additional Manufacturer Narrative
Product complaint # (b)(4).Investigation summary examination of the returned device finds no defect present depuy synthes considers the investigation closed.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).Where the product and lot code was provided, a manufacturing records evaluation (mre) was not performed.

• Brand Name: SIGMA PS CEM FEM SZ3 L
• Common Device Name: SIGMA KNEE PRIMARY : KNEE FEMORAL
• Manufacturer (Section D): DEPUY ORTHOPAEDICS INC US; 700 orthopaedic drive; warsaw IN 46581 0988
• MDR Report Key: 12373119
• Report Number: 1818910-2021-18763
• Device Sequence Number: 19817283
• Product Code: JWH
• UDI-Device Identifier: 10603295075042
• UDI-Public: 10603295075042
• Combination Product (Y/N): N
• Initial Reporter State: VA
• Initial Reporter Country: US
• PMA/510(K) Number: P830055
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2008
• Device Explanted Year: 2021
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 08/09/2021

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: 1960-40-300
• Device Catalogue Number: 196040300
• Device Lot Number: C4BDC4
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 08/23/2021
• Initial Date Received by Manufacturer: 08/09/2021
• Supplement Date Received by Manufacturer: 08/23/2021; 09/30/2021
• Initial Report FDA Received Date: 08/26/2021
• Supplement Report FDA Received Date: 09/02/2021; 10/01/2021
• 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: BONE CEMENT (MFG. AND PRODUCT NAME UNKNOWN).; MBT CEM KEEL TIB TRAY SZ3.; PFC SIGMARP STB TB IN 3 12.5.; PFC*SIGMA/RD/DOME PAT 3PEG,38.; SIGMA PS CEM FEM SZ3 L.; BONE CEMENT (MFG. AND PRODUCT NAME UNKNOWN); MBT CEM KEEL TIB TRAY SZ3; PFC SIGMARP STB TB IN 3 12.5; PFC*SIGMA/RD/DOME PAT 3PEG,38; SIGMA PS CEM FEM SZ3 L
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 72 YR