MAUDE Adverse Event Report: MEDACTA INTERNATIONAL SA GMK-REVISION FIXED TIBIAL INSERT SC SIZE 3/12MM; KNEE TIBIAL INSERT REVISION SYSTEM

Model Number	02.07.0312SCF
Medical Device Problem Code	Device Appears to Trigger Rejection (1524)
Health Effect - Clinical Code	Unspecified Infection (1930)
Date of Event	05/25/2023
Type of Reportable Event	Serious Injury
Event or Problem Description
At about 4 years 8 months after the primary, the patient came in due to signs of infection and the pathogen is unknown.The surgeon performed a washout and poly swap and the surgery was completed successfully.The primary was from a competitor and the surgeon revised the competitor to medacta revision components.
Additional Manufacturer Narrative
Batch review performed on 01 june 2023: lot 183190: (b)(4) items manufactured and released on 19-july-2018.Expiration date: 2023-07-16.No anomalies found related to the problem.To date, (b)(6) items of the same lot have been sold with another similar reported event during the period of review.

• Brand Name: GMK-REVISION FIXED TIBIAL INSERT SC SIZE 3/12MM
• Common Device Name: KNEE TIBIAL INSERT REVISION SYSTEM
• Manufacturer (Section D): MEDACTA INTERNATIONAL SA; strada regina; castel san pietro, switzerland 6874 ; SZ 6874
• Manufacturer (Section G): MEDACTA INTERNATIONAL SA; strada regina; castel san pietro, switzerland 6874 ; SZ 6874
• Manufacturer Contact: marco giannessi ; strada regina; castel san pietro, switzerland 6874 ; SZ 6874
• MDR Report Key: 17190244
• Report Number: 3005180920-2023-00450
• Device Sequence Number: 14904674
• Product Code: JWH
• UDI-Device Identifier: 07630030817175
• UDI-Public: 07630030817175
• Combination Product (Y/N): N
• Initial Reporter State: MO
• Initial Reporter Country: US
• PMA/510(K) Number: K103170
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2018
• Device Explanted Year: 2023
• 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): 06/23/2023

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: 07/16/2023
• Device Model Number: 02.07.0312SCF
• Device Catalogue Number: 02.07.0312SCF
• Device Lot Number: 183190
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 05/25/2023
• Initial Report FDA Received Date: 06/23/2023
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 07/19/2018
• 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: Female