MAUDE Adverse Event Report: EXACTECH, INC. OPTETRAK; CC TIBIAL INSERT SZ 4, 9MM

Model Number	208-24-09
Medical Device Problem Codes	Naturally Worn (2988); Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	10/24/2019
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Pending evaluation.
Event or Problem Description
As reported, approximately 6.13 years since initial implant, this male patient with bmi 30.8 underwent left side tka and was implanted with an exactech uhmwpe insert, serial #: (b)(4).On (b)(6) 2019, the patient underwent revision due to instability and polyethylene wear.No additional information is available or forthcoming.
Additional Manufacturer Narrative
(h3) the revision reported may have been the result of malalignment between the femoral and tibial components, third body wear, patient-related conditions, or any combination of these possibilities, which led to prosthesis wear and instability.However, this cannot be confirmed as the devices were not available for evaluation and pre-revision x-rays were not provided.Section h11: the following sections have corrected information: (h6) medical device problem code: 2988, naturally worn, component code: 734, known inherent risk of device.

• Brand Name: OPTETRAK
• Common Device Name: CC TIBIAL INSERT SZ 4, 9MM
• Manufacturer (Section D): EXACTECH, INC.; 2320 nw 66 court; gainesville FL 32653
• Manufacturer (Section G): EXACTECH, INC.; 2320 nw 66 ct; gainesville FL 32653
• Manufacturer Contact: kate jacobson kate jacobson ; 3523771140
• MDR Report Key: 13413500
• Report Number: 1038671-2022-00096
• Device Sequence Number: 17175851
• Product Code: JWH
• UDI-Device Identifier: 10885862054326
• UDI-Public: 10885862054326
• Combination Product (Y/N): N
• Initial Reporter State: NY
• Initial Reporter Country: US
• PMA/510(K) Number: K954208
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2013
• Device Explanted Year: 2019
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 08/15/2022

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: 03/26/2016
• Device Model Number: 208-24-09
• Device Catalogue Number: 208-24-09
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 01/07/2022
• Supplement Date Received by Manufacturer: 07/22/2022
• Initial Report FDA Received Date: 02/01/2022
• Supplement Report FDA Received Date: 08/15/2022
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 03/29/2011
• 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: Hospitalization; Required Intervention
• Patient Sex: Male