MAUDE Adverse Event Report: MICROPORT ORTHOPEDICS INC. ADVANCE® II REVISION CCK INSERT SIZE 4 STANDARD 17; KNEE COMPONENT

Model Number	KIRV417S
Medical Device Problem Code	Insufficient Device Problem Information (3190)
Health Effect - Clinical Code	Unspecified Infection (1930)
Type of Reportable Event	Serious Injury
Event or Problem Description
Allegedly, patient underwent tka in the uk, date unknown.Revised on (b)(6) 2025 due to infection.Tibial insert revised with another of the same size.Insert supplied under sas category b, tga approval ref (b)(4).Non-revised products: porduct id: kttinp40 advance® ii modular titanium tibial base sz 4 std nonporous/ lot no.: 1559477/ qty: 1.Porduct id: ksp16140 advance® canal filling stem extension 17mm x 140mm/ lot no.: 1409427/ qty: 1.Porduct id: kfccnp4r advance® revision femoral size 4 right nonporous/ lot no.: 1542396/ qty: 1.Porduct id: ksp14100 advance® canal filling stem extension 15mm x 100mm/ lot no.: 1409425/ qty: 1.Porduct id: kpontp35 advance® onlay all-poly patella 35mm tri-peg/ lot no.: 1580890/ qty: 1 australia (b)(4).
Additional Manufacturer Narrative
This event will be updated once the investigation is complete.Trends will be evaluated.

• Brand Name: ADVANCE® II REVISION CCK INSERT SIZE 4 STANDARD 17
• Common Device Name: KNEE COMPONENT
• Manufacturer (Section D): MICROPORT ORTHOPEDICS INC.; 5677 airline rd.; arlington TN 38002
• Manufacturer Contact: rachael wise ; 5677 airline road; arlington, TN 38002 ; 9018674771
• MDR Report Key: 22154451
• Report Number: 3010536692-2025-00275
• Device Sequence Number: 15403487
• Product Code: JWH
• UDI-Device Identifier: M684KIRV417S1
• UDI-Public: M684KIRV417S1
• Combination Product (Y/N): N
• Initial Reporter Country: AS
• PMA/510(K) Number: K990030
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Explanted Year: 2025
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Distributor
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 07/31/2025

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: Other
• Device Model Number: KIRV417S
• Device Catalogue Number: KIRV417S
• Device Lot Number: 1573334
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 05/12/2025
• Supplement Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 06/05/2025
• Supplement Report FDA Received Date: 07/31/2025
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Is the Device Labeled for Single Use? (Y/N): Yes
• Usage of Device: Initial
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 64 YR
• Patient Sex: Male