MAUDE Adverse Event Report: DEPUY RAYNHAM ¿ 1219655 PFC*SIGMA DIS AUG 4MM,SZ4,LEFT; KNEE OTHER IMPLANT

Catalog Number	960880
Medical Device Problem Code	Loss of or Failure to Bond (1068)
Health Effect - Clinical Codes	Osteolysis (2377); No Code Available (3191)
Date of Event	07/19/2017
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.
Event or Problem Description
The patient was revised to address osteolysis and aseptic loosening of the femoral and tibia at the unknown interface.
Additional Manufacturer Narrative
The device associated with this report was not received for examination depuy considers the investigation closed.Should additional information be received, the information will be reviewed and the investigation will be re-opened as necessary.If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.

• Common Device Name: KNEE OTHER IMPLANT
• Manufacturer (Section D): DEPUY RAYNHAM ¿ 1219655; 325 paramount drive; raynham MA 02767
• MDR Report Key: 6843011
• Report Number: 1818910-2017-24044
• Device Sequence Number: 460845
• Product Code: JWH
• UDI-Device Identifier: 10603295234364
• UDI-Public: 10603295234364
• Combination Product (Y/N): N
• Initial Reporter State: CA
• Initial Reporter Country: US
• PMA/510(K) Number: K952830
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2001
• Device Explanted Year: 2017
• Reporter Type: Manufacturer
• Report Source: study
• Initial Reporter Occupation: Health Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 08/07/2017

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 Catalogue Number: 960880
• Device Lot Number: 224567
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 08/07/2017
• Supplement Date Received by Manufacturer: 09/25/2017
• Initial Report FDA Received Date: 09/05/2017
• Supplement Report FDA Received Date: 09/27/2017
• 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: Required Intervention
• Patient Age: 65 YR
• Patient Weight: 107