MAUDE Adverse Event Report: MEDACTA INTERNATIONAL SA GMK-HINGE 02.07.0036RP PATELLA RESURFACING SIZE 4; KNEE PATELLA RESURFACING

Model Number	02.07.0036RP
Health Effect - Clinical Code	Unspecified Infection (1930)
Date of Event	04/07/2022
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Batch review performed on 12 april 2022.Lot 2109460: (b)(4) items manufactured and released on 30-sep-2021.Expiration date: 2026-sep-15.No anomalies found related to the problem.To date, (b)(4) items of the same lot have been sold with no similar reported event.Other device involved: batch review performed on 12 april 2022.Gmk-hinge 02.09.0414h fixed tibial insert size 4/14mm (k130299) lot 189416: (b)(4) items manufactured and released on 01-feb-2019.Expiration date: 2024-feb-04.No anomalies found related to the problem.To date, (b)(4) items of the same lot have been sold with no similar reported event.
Event or Problem Description
The patient had a primary knee surgery on (b)(6) 2021.On (b)(6) 2021, the patient came in for a post-op appointment and it was determined that the patient needed to be converted because the patients quadriceps wasn't strong enough and was causing the knee to hyperextend.All components were revised and the surgery was completed successfully.Presently, on (b)(6) 2022, the patient came in due to signs of an infection and the pathogen is unknown.The surgeon performed a washout and revised the poly and patella.The surgery was completed successfully.

• Brand Name: GMK-HINGE 02.07.0036RP PATELLA RESURFACING SIZE 4
• Common Device Name: KNEE PATELLA RESURFACING
• 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: 14317033
• Report Number: 3005180920-2022-00335
• Device Sequence Number: 12061830
• Product Code: JWH
• UDI-Device Identifier: 07630030815775
• UDI-Public: 07630030815775
• Combination Product (Y/N): N
• Initial Reporter State: IL
• Initial Reporter Country: US
• PMA/510(K) Number: K113571
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2021
• Device Explanted Year: 2022
• 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): 05/06/2022

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 Expiration Date: 09/15/2026
• Device Model Number: 02.07.0036RP
• Device Catalogue Number: 02.07.0036RP
• Device Lot Number: 2109460
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 04/07/2022
• Initial Report FDA Received Date: 05/07/2022
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 09/30/2021
• 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: Required Intervention
• Patient Sex: Male