MAUDE Adverse Event Report: MICROPORT ORTHOPEDICS INC. EVOLUTION® MP? CS INSERT SIZE 5+ 10MM RIGHT; KNEE COMPONENT

Model Number	EIS5P10R
Medical Device Problem Code	Unstable (1667)
Health Effect - Clinical Code	Insufficient Information (4580)
Type of Reportable Event	Serious Injury
Event or Problem Description
Allegedly, patient was revised due to instability.No revised: product id: efsrn6pr, evolution mp fem cs/cr non-por primary sz 6 right, lot: 1845073, qty: 1.Product id: etpkn5sr, evolution mp tibial keeled nonpor size 5 standard right, lot: 1821271, qty: 1.Product id: kpontp32, advance onlay all poly patella 32mm tripeg, lot: 1880365, qty: 1.Revision njr number: (b)(4), side: r , primary asa: p2 - mild disease not incapacitating.

• Brand Name: EVOLUTION® MP? CS INSERT SIZE 5+ 10MM RIGHT
• Common Device Name: KNEE COMPONENT
• Manufacturer (Section D): MICROPORT ORTHOPEDICS INC.; 5677 airline rd.; arlington TN 38002
• Manufacturer (Section G): MICROPORT ORTHOPEDICS INC.; 5677 airline rd.; arlington TN 38002
• Manufacturer Contact: 5677 airline road; arlington, TN 38002 ; 9018674771
• MDR Report Key: 14029070
• Report Number: 3010536692-2022-00114
• Device Sequence Number: 14646360
• Product Code: HRY
• UDI-Device Identifier: M684EIS5P10R1
• UDI-Public: M684EIS5P10R1
• Combination Product (Y/N): N
• Initial Reporter Country: UK
• PMA/510(K) Number: K093552
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2021
• Device Explanted Year: 2022
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 04/06/2022

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: EIS5P10R
• Device Catalogue Number: EIS5P10R
• Device Lot Number: 1788879
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 03/15/2022
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 03/15/2022
• Initial Report FDA Received Date: 04/06/2022
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Is the Device Labeled for Single Use? (Y/N): Yes
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Sex: Unknown