MAUDE Adverse Event Report: MEDACTA INTERNATIONAL SA GMK-PRIMARY TIBIAL INSERT UC FIXED SIZE 4 / 20 MM; KNEE TIBIAL INSERT

Model Number	02.07.0420FUC
Health Effect - Clinical Code	Joint Laxity (4526)
Date of Event	06/06/2022
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Batch review performed on 14 june 2022: lot 133337: (b)(4) items manufactured and released on 10-oct-2013.Expiration date: 2018-08-31.No anomalies found related to the problem.To date, (b)(4) items of the same lot have been sold without any similar reported event during the period of review.Additional implant involved: batch review performed on 14 june 2022 gmk-primary 02.07.1204r tibial tray fixed cemented size 4 r (k090988) lot 136136: (b)(4) items manufactured and released on 11-mar-2014.Expiration date: 2019-01-31.No anomalies found related to the problem.To date, (b)(4) items of the same lot have been sold without any similar reported event during the period of review.
Event or Problem Description
The patient had a primary knee surgeon on (b)(6) 2015.On (b)(6) 2017, the patient fell and came in reporting laxity.The surgery swapped the 12mm poly for a 17mm poly.On (b)(6) 2017, the patient was revised again.The patient fell and came in reporting laxity.The surgeon swapped the 17mm insert for a 20mm insert.The surgery was completed successfully.On (b)(6) 2022, the patient came in reporting instability due to laxity and the cause is unknown.The surgeon revised the insert and tibial tray and the surgery was completed successfully.

• Brand Name: GMK-PRIMARY TIBIAL INSERT UC FIXED SIZE 4 / 20 MM
• Common Device Name: KNEE TIBIAL INSERT
• 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: 14927433
• Report Number: 3005180920-2022-00507
• Device Sequence Number: 5813940
• Product Code: JWH
• UDI-Device Identifier: 07630030818035
• UDI-Public: 07630030818035
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K090988
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2015
• Device Explanted Year: 2022
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Other
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 07/06/2022

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: 08/31/2018
• Device Model Number: 02.07.0420FUC
• Device Catalogue Number: 02.07.0420FUC
• Device Lot Number: 133337
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 06/06/2022
• Initial Report FDA Received Date: 07/06/2022
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 10/10/2013
• 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