MAUDE Adverse Event Report: MEDACTA INTERNATIONAL SA GMK-PRIMARY 02.07.0512PSF TIBIAL INSERT PS FIXED SIZE 5/12MM

Model Number	02.07.0512PSF
Health Effect - Clinical Code	Unspecified Infection (1930)
Date of Event	10/29/2021
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Batch review performed on 4 november 2021: lot 179576: (b)(4) items manufactured and released on 22-mar-2018.Expiration date: 2023-mar-09.No anomalies found related to the problem.To date, (b)(4) items of the same lot have been sold with one similar reported event.
Event or Problem Description
The patient came in due to signs of an infection and the pathogen is unknown.About 1 year and 10 months after the primary surgery, the surgeon performed a washout and revised the poly and the surgery was completed successfully.

• Brand Name: GMK-PRIMARY 02.07.0512PSF TIBIAL INSERT PS FIXED SIZE 5/12MM
• Common Device Name: TIBIAL INSERT
• Manufacturer (Section D): MEDACTA INTERNATIONAL SA; strada regina; castel san pietro, 6874 ; SZ 6874
• Manufacturer (Section G): MEDACTA INTERNATIONAL SA; strada regina; castel san pietro, 6874 ; SZ 6874
• Manufacturer Contact: stefano baj ; strada regina; castel san pietro, switzerland 6874 ; SZ 6874
• MDR Report Key: 12874310
• Report Number: 3005180920-2021-00921
• Device Sequence Number: 4353353
• Product Code: JWH
• UDI-Device Identifier: 07630030818325
• UDI-Public: 07630030818325
• Combination Product (Y/N): N
• Initial Reporter State: IL
• Initial Reporter Country: US
• PMA/510(K) Number: K090988
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2019
• 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
• Report Date (Section B): 11/25/2021

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: 03/09/2023
• Device Model Number: 02.07.0512PSF
• Device Catalogue Number: 02.07.0512PSF
• Device Lot Number: 179576
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 10/29/2021
• Initial Report FDA Received Date: 11/25/2021
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 03/22/2018
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Other
• Patient Sex: Male