MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS INC US LPS UNIV TIB HIN INS MED 16MM; LPS AND S-ROM : KNEE TIBIAL INSERT

Model Number	1987-27-316
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Fall (1848); Inflammation (1932); Pain (1994); Joint Laxity (4526)
Date of Event	09/22/2022
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Product complaint # (b)(4).Depuy synthes is submitting this report pursuant to the provisions of 21 cfr, part 803.This report may be based on information which depuy synthes has not been able to investigate or verify prior to the required reporting date.This report does not reflect a conclusion by fda, depuy synthes or its employees that the report constitutes an admission that the device, depuy synthes, or its employees caused or contributed to the potential event described in this report.If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.
Event or Problem Description
Patient underwent the initial procedure on (b)(6) 2022 (received an s-rom noiles rotating hinge knee).The patient felt his knee "give way", followed by significant pain.Upon investigation it was discovered that the "boss" for the sleeve attachment on the femoral component had broken resulting in failure of the construct.The patient underwent revision surgery and the damaged femoral components were removed and revised to an lps distal femoral replacement.The retrieved implants were sent to the bio-engineering department at (b)(6) hospital as per standard protocol here in (b)(6).If other, describe: n/a, if other, describe : revision knee surgery., patient status/ outcome / consequences : yes, patient consequence description/was there a clinical outcome experienced by the patient (infection, inflammation, etc.)? pain, inflammation, was other medical intervention (e.G.X-rays, additional procedures, prescriptions, otc, revision) required: yes, if yes, describe : x-rays, revision surgery, other information : n/a, is the patient part of a clinical study : unknown, (b)(4).Device property of: none, device in possession of: none, (b)(4).Device property of : none, device in possession of : none, (b)(4).Device property of : none, device in possession of : none, (b)(4).Device property of : none, device in possession of : none.By checking this box i certify that all information that are known/available has been disclosed.If any new information will be made available, the additional information will be submitted through cst.True.
Additional Manufacturer Narrative
Product complaint # (b)(4).Investigation summary : the device associated with this complaint was not returned.Photo evidence and x-rays provided were reviewed and found no product issue.Additional monitoring for any potential safety signals will be conducted through complaint trending and other post-market safety surveillance activities.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 UNIV TIB HIN INS MED 16MM
• Common Device Name: LPS AND S-ROM : KNEE TIBIAL INSERT
• 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: kate karberg ; 700 orthpaedic dr.; warsaw, IN 46581 ; 3035526892
• MDR Report Key: 15566819
• Report Number: 1818910-2022-19879
• Device Sequence Number: 19538500
• Product Code: KRO
• UDI-Device Identifier: 10603295079590
• UDI-Public: 10603295079590
• Combination Product (Y/N): N
• Initial Reporter Country: AS
• PMA/510(K) Number: K091453
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2022
• Device Explanted Year: 2022
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Foreign,Health Professional,Company Representative
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 10/07/2022

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: 1987-27-316
• Device Catalogue Number: 198727316
• Device Lot Number: J33D82
• 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: 09/22/2022
• Supplement Date Received by Manufacturer: 11/28/2022
• Initial Report FDA Received Date: 10/07/2022
• Supplement Report FDA Received Date: 11/28/2022
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 04/15/2019
• 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: SROM NRHFEM W/PIN MED RT 71X66; UNIVERSAL FEM SLV FUL POR 46MM; UNIVERSAL STEM 150X16MM FLUTED
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Sex: Male