MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS INC US LCS COMP RP INSERT LG 12.5MM; LCS COMPLETE : KNEE TIBIAL INSERT

Catalog Number	129405612
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Foreign Body Reaction (1868); Pain (1994); Joint Laxity (4526)
Date of Event	12/14/2023
Type of Reportable Event	Serious Injury
Event or Problem Description
Revision left knee.Primary implants - right lcs femur, 12.5mm insert and size 5 tibia.Revision for subsidence and loosening of components.Femur removed by hand - clean (cement left on bone - no cement details available).Tibia removed very easily as well with cement all attached to bone and not implant.Dark metallosis appeared on knee tissue, no signs of infection.Surgeon washed, debrided then revised using attune revision.
Additional Manufacturer Narrative
Product complaint # (b)(4).This report is being submitted pursuant to the provisions of 21 cfr, part 803 (and/or part 4, as applicable).This report may be based on information which has not been investigated or verified prior to the required reporting date.This report does not reflect a conclusion by depuy synthes, or its employees that the report constitutes an admission that the product, 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 report, a follow-up report will be filed as appropriate.
Additional Manufacturer Narrative
Product complaint # (b)(4).This report is being submitted pursuant to the provisions of 21 cfr, part 803.This report may be based on information which has not been investigated or verified prior to the required reporting date.This report does not reflect a conclusion by depuy synthes joint reconstruction, or its employees that the report constitutes an admission that the product, depuy synthes joint reconstruction, 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 report, a follow-up report will be filed as appropriate.
Additional Manufacturer Narrative
Product complaint # (b)(4).Investigation summary : according to the information received: revision left knee.Primary surgery completed by [surgeon]- unknown surgery date and hospital.Primary implants - right lcs femur, 12.5mm insert and size 5 tibia.Revision for subsidence and loosening of components.Femur removed by hand - clean (cement left on bone no cement details available).Tibia removed very easily as well with cement all attached to bone and not implant.Dark metallosis appeared on knee tissue, no signs of infection.Surgeon washed, debrided then revised using attune revision.The product was not returned to depuy synthese, however photos were provided for review.The photo evidence review for lcs comp rp insert lg 12.5mm found groove and pitting patterns on the underside of device, which is likely to happen due to cement fragments breaking off and floating in the joint space in between the tray and the insert, causing wear.Since the device was not returned, a dimensional inspection cannot be performed.The overall complaint was confirmed as the observed condition of the lcs comp rp insert lg 12.5mm would contribute to a device issue.Based on the investigation findings it has been determined that no corrective and/or preventative action is proposed.There is no indication that a design or manufacturing issue has caused the complaint condition.As part of depuy synthes quality process, all devices are manufactured, inspected, and released to approved specifications.Additional monitoring for any potential safety signals will be conducted through complaint trending and other post-market safety surveillance activities.Device history lot: a manufacturing record evaluation was performed for the finished device product description: lcs comp rp insert lg 12.5mm product code: 129405612 lot number: 300336 and no non-conformances or manufacturing irregularities were identified.Device history review : a manufacturing record evaluation was performed for the finished device product description: lcs comp rp insert lg 12.5mm product code: 129405612 lot number: 300336 and no non-conformances or manufacturing irregularities were identified.

• Brand Name: LCS COMP RP INSERT LG 12.5MM
• Common Device Name: LCS COMPLETE : KNEE TIBIAL INSERT
• Manufacturer (Section D): DEPUY ORTHOPAEDICS INC US; 700 orthopaedic drive; warsaw IN 46581 0988
• Manufacturer (Section G): JTE RAYNHAM MFG SITE; 325 paramount drive; raynham MA
• Manufacturer Contact: kate karberg ; 700 orthopaedic dr.; warsaw, IN 46581-0988 ; 3035526892
• MDR Report Key: 18383112
• Report Number: 1818910-2023-25931
• Device Sequence Number: 7797325
• Product Code: NJL
• UDI-Device Identifier: 10603295022169
• UDI-Public: 10603295022169
• Combination Product (Y/N): N
• Initial Reporter Country: AS
• PMA/510(K) Number: P830055
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Explanted Year: 2023
• 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,Followup

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: 10/31/2017
• Device Catalogue Number: 129405612
• Device Lot Number: 300336
• 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: 12/14/2023
• Supplement Date Received by Manufacturer: 01/02/2024; 02/05/2024
• Initial Report FDA Received Date: 12/22/2023
• Supplement Report FDA Received Date: 01/03/2024; 02/06/2024
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 10/26/2012
• 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: LCS COMPLETE FEM CEM R LG; MBT CEM TIBIAL TRAY SZ5; UNKNOWN BONE CEMENT
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Sex: Unknown