MAUDE Adverse Event Report: ENCORE MEDICAL, L.P. FOUNDATION POSTERIOR STABILIZED (PS) KNEE; INSERT, CONSTRAINED, P.S., SIZE4 19MM CM

Model Number	370-19-504
Health Effect - Clinical Code	Unspecified Infection (1930)
Date of Event	12/28/2016
Type of Reportable Event	Serious Injury
Event or Problem Description
Revision surgery - due to a small minor infection; the surgeon replaced all of the components.
Additional Manufacturer Narrative
The reason for this revision surgery was an infection.The previous surgery and the revision detailed in this investigation occurred 43 days apart.No information was submitted with the complaint regarding pre-existing conditions of the patient or any activities the patient was involved in that may have contributed to the possible infection or inhibited the patient's immune system.The healthcare professional indicated 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 implant device history records (dhrs) show that the reported component used in the previous surgery met design and manufacturing requirements.There were no non-conforming material reports (ncmrs) associated with the product that may have contributed to an infection.The device was verified to have gone through an acceptable sterilization process and was within it's expiration date at the time of use during the previous surgery.There were no findings during this investigation that indicate that the reported device was the root cause or had a direct connection with the patient's infection.Due to the short time between the original surgery and the revision, it is possible that the infection was acquired in the hospital (nosocomial).It is also possible that the patient was not compliant with post surgical instructions.There are multiple factors that may contribute to an infection that are outside of the control of djo surgical.There are no indications of a product or process issue affecting implant safety or effectiveness.
Additional Manufacturer Narrative
Corrected information provided.Follow up 2 was reported as a combination product, the product is not a combination product.Additional reporting on this event will be provided as a supplemental report to this document as soon as it becomes available.
Additional Manufacturer Narrative
Additional narrative: additional concomitant items needed to be added to the mdr complaint.Additional reporting on this event will be provided as a supplemental report to this document if it becomes available.

• Brand Name: FOUNDATION POSTERIOR STABILIZED (PS) KNEE
• Common Device Name: INSERT, CONSTRAINED, P.S., SIZE4 19MM CM
• Manufacturer (Section D): ENCORE MEDICAL, L.P.; 9800 metric blvd.; austin TX 78758
• MDR Report Key: 6266496
• Report Number: 1644408-2017-00036
• Device Sequence Number: 19033378
• Product Code: JWH
• UDI-Device Identifier: 00888912116862
• UDI-Public: (01)00888912116862
• Combination Product (Y/N): N
• Initial Reporter State: MS
• Initial Reporter Country: US
• PMA/510(K) Number: K933539
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2016
• Device Explanted Year: 2016
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup,Followup,Followup
• Report Date (Section B): 07/16/2021

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: 11/28/2018
• Device Model Number: 370-19-504
• Device Catalogue Number: 370-19-504
• Device Lot Number: 59604219
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 12/28/2016
• Supplement Date Received by Manufacturer: Not provided; 02/01/2017; 07/15/2021
• Initial Report FDA Received Date: 01/20/2017
• Supplement Report FDA Received Date: 03/01/2017; 02/08/2021; 07/16/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: 205-01-006,LOT 750A1027
• Outcome Attributed to Adverse Event: Hospitalization; Required Intervention
• Patient Age: 68 YR