MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS INC US LPS FEM TO SLEEVE ADAPTER +10; LPS AND S-ROM : KNEE FEMORAL ACCESSORY

Model Number	1987-06-010
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Unspecified Infection (1930)
Date of Event	12/15/2021
Type of Reportable Event	Serious Injury
Event or Problem Description
It was reported amputation was done.Doi: (b)(6) 2015, dor: (b)(6) 2016, unknown knee side.
Additional Manufacturer Narrative
Product complaint # (b)(4).This complaint is linked to (b)(4) i&d and revision event.This complaint is linked to (b)(4).Where patellar fracture with an intact patellar button was reported.If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.
Additional Manufacturer Narrative
Product complaint (b)(4).Investigation summary: no device associated with this report was received for examination.All available x-rays were reviewed, and no evidence of implant fracture, disassociation, or anything indicative of a device nonconformance was found.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: LPS FEM TO SLEEVE ADAPTER +10
• Common Device Name: LPS AND S-ROM : KNEE FEMORAL ACCESSORY
• Manufacturer (Section D): DEPUY ORTHOPAEDICS INC US; 700 orthopaedic drive; warsaw IN 46581 0988
• Manufacturer (Section G): DEPUY ORTHOPAEDICS, INC. 1818910; 700 orthopaedic dr.; warsaw IN 46581 0988
• Manufacturer Contact: kara ditty-bovard ; 700 orthopaedic dr.; warsaw, IN 46581-0988 ; 6107428552
• MDR Report Key: 13549321
• Report Number: 1818910-2022-02987
• Device Sequence Number: 5186481
• Product Code: MBH
• UDI-Device Identifier: 10603295078500
• UDI-Public: 10603295078500
• Combination Product (Y/N): N
• Initial Reporter Country: CA
• PMA/510(K) Number: K071417
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2015
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Foreign,Study,Health Professional
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 02/17/2022

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 Model Number: 1987-06-010
• Device Catalogue Number: 198706010
• Device Lot Number: 538961
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 02/04/2022
• Supplement Date Received by Manufacturer: 03/09/2022
• Initial Report FDA Received Date: 02/17/2022
• Supplement Report FDA Received Date: 03/09/2022
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 06/23/2014
• 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
• Concomitant Medical Products and Therapy/Usage Dates: LPS DISTAL FEM COMP XSM LT.; LPS FEM TO SLEEVE ADAPTER +10.; LPS UNIV TIB HIN INS XSM 12MM.; MBT REVISION CEM TIB TRAY SZ 3.; P.F.C. TIB STM EXT 4/5/6 60MM.; PFC SIGMA/OV DOME PAT 3 PEG,32.; S&N RESTRICTOR CEMENT 129419/14JSM0243.; SROM NRH REPL HINGE PIN/XSM/SM.; STRYKER CEMENT 61971001.; STRYKER CEMENT 61971001.; STRYKER CEMENT 61971001.; STRYKER CEMENT 61971001.; UNIVERSAL FEM SLV DIS POR 34MM.; UNIVERSAL STEM 75X18MM FLUTED.; UNKNOWN KNEE FEMORAL ADAPTOR BOLT.
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 63 YR
• Patient Sex: Female
• Patient Weight: 158 KG