MAUDE Adverse Event Report: MEDACTA INTERNATIONAL SA GMK-REVISION FIXED TIBIAL INSERT SEMICONSTRAINED S.1 / 12 MM; KNEE TIBIAL INSERT SEMICONSTRAINED

Catalog Number	02.07.0112SCF
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Joint Laxity (4526)
Date of Event	08/07/2023
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Batch review performed on 09 august 2023: lot 184305: 18 items manufactured and released on 16-aug-2018.Expiration date: 2023-07-26.No anomalies found related to the problem.To date, 3 items of the same lot have been sold without any similar reported event in the period of review.
Event or Problem Description
The patient came in reporting instability due to laxity.At 3 years and 8 months post operative the surgeon revised the 12mm poly with a 17mm poly and the surgery was completed successfully.

• Brand Name: GMK-REVISION FIXED TIBIAL INSERT SEMICONSTRAINED S.1 / 12 MM
• Common Device Name: KNEE TIBIAL INSERT SEMICONSTRAINED
• 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: 17689782
• Report Number: 3005180920-2023-00666
• Device Sequence Number: 17671384
• Product Code: JWH
• UDI-Device Identifier: 07630030816017
• UDI-Public: 07630030816017
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K103170
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2019
• Device Explanted Year: 2023
• 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): 09/06/2023

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: 07/26/2023
• Device Catalogue Number: 02.07.0112SCF
• Device Lot Number: 184305
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 08/07/2023
• Initial Report FDA Received Date: 09/06/2023
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 08/16/2018
• 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 Age: 73 YR
• Patient Sex: Female
• Patient Weight: 66 KG
• Patient Race: White