MAUDE Adverse Event Report: ENCORE MEDICAL, L.P. FOUNDATION KNEE; INSERT, STD., PRIMARY, SIZE10 9MM CM

Catalog Number	385-09-510
Health Effect - Clinical Code	Pain (1994)
Date of Event	12/15/2015
Type of Reportable Event	Serious Injury
Event or Problem Description
Revision surgery - due to the patient presenting with pain when weight-bearing.The surgeon felt that with the age of the joint that the poly had worn and decided to replace it.
Additional Manufacturer Narrative
The reason for this revision surgery was pain due to the poly being worn.The length of in vivo service was 11.5 years.There is no information in this complaint about any patient injuries, activities, or accidents that may have contributed to the need for this revision surgery.The healthcare professional indicated there was a significant adverse event to the patient.There was no delay in surgery and another suitable device was available for use.The revision surgery was completed as intended.The device was disposed of at the hospital and not made available to djo surgical for examination.A review of the device history records showed no non-conforming material reports associated with the main contributor component listed in the complaint.A review of the product complaint report history showed there have been 7 prior complaints reported against this part number; summary of investigations: 2 wear, 2 instability, 2 infections, 1 trauma.This is the first complaint against this lot number.This event is deemed to be non-product related.The surgeon believed the poly had worn as result of the implant age, reported no issues associated with the explanted product, and provided no information that definitively described the root cause or reason of the joint wear other than age of the insert.The scope of this investigation is limited without having the parts available to djo surgical for evaluation.Other conditions relating to this event could not be determined with confidence.Inventory containment is not required as there are no indications of a product or process issue affecting implant safety or effectiveness.

• Brand Name: FOUNDATION KNEE
• Common Device Name: INSERT, STD., PRIMARY, SIZE10 9MM CM
• Manufacturer (Section D): ENCORE MEDICAL, L.P.; 9800 metric blvd.; austin TX 78758
• MDR Report Key: 5367418
• Report Number: 1644408-2015-00792
• Device Sequence Number: 518030
• Product Code: JWH
• UDI-Device Identifier: 00888912117777
• UDI-Public: (01)00888912117777
• Combination Product (Y/N): N
• Initial Reporter State: OK
• Initial Reporter Country: US
• PMA/510(K) Number: K000590
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2004
• Device Explanted Year: 2015
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Other
• Type of Report: Followup
• Report Date (Section B): 12/15/2015

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: 04/30/2009
• Device Catalogue Number: 385-09-510
• Device Lot Number: 994811
• Was Device Available for Evaluation?: No
• Type of Report(Section G): FDA Requested
• Initial Date Received by Manufacturer: Not provided
• Supplement Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 01/14/2016
• Supplement Report FDA Received Date: 06/09/2016
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Other; Required Intervention
• Patient Age: 63 YR