MAUDE Adverse Event Report: EXACTECH, INC. OPTETRAK; CC TIBIAL INSERT SZ 4, 11MM

Model Number	208-24-11
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Osteolysis (2377)
Date of Event	06/22/2021
Type of Reportable Event	Serious Injury
Event or Problem Description
As reported, approximately 11.60 years since initial implant, this male patient with bmi 23.8 underwent a left side tka and was implanted with an exactech uhmwpe insert, serial # (b)(4).On (b)(6) 2021, the patient underwent revision due to osteolysis.No additional information is available or forthcoming.
Additional Manufacturer Narrative
Pending evaluation.
Additional Manufacturer Narrative
Section h10: (h3) the reason for revision reported was not provided but was likely the result of wear, loosening, infection, fracture, instability, or patient related factors.The reported osteolysis may have also contributed to the revision and may have been a result of patient related conditions and/or prosthesis wear.However, this cannot be confirmed because the component was not returned for evaluation and additional information was not provided.

• Brand Name: OPTETRAK
• Common Device Name: CC TIBIAL INSERT SZ 4, 11MM
• 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 ; 3523771140
• MDR Report Key: 13451401
• Report Number: 1038671-2022-00170
• Device Sequence Number: 5046767
• Product Code: JWH
• UDI-Device Identifier: 10885862054333
• UDI-Public: 10885862054333
• 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: 2009
• Device Explanted Year: 2021
• Reporter Type: Manufacturer
• Report Source: Health Professional,Company Representative
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 07/01/2022

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: 07/16/2013
• Device Model Number: 208-24-11
• Device Catalogue Number: 208-24-11
• 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: 06/14/2022
• Initial Report FDA Received Date: 02/04/2022
• Supplement Report FDA Received Date: 07/01/2022
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 03/26/2009
• 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