MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS, INC.1818910 SROM*EXTENSN,TIB STEM,11X150MM; KNEE OTHER IMPLANT

Catalog Number	627115
Medical Device Problem Code	Fracture (1260)
Health Effect - Clinical Codes	Foreign Body Reaction (1868); Joint Dislocation (2374); No Code Available (3191)
Date of Event	08/17/2017
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
Planned revision of tibial components because of fracture of tibial extension(s).See x-rays.Update: (b)(6) 2017 patient revised (b)(6) 2017.
Additional Manufacturer Narrative
The complaint states planned revision of tibial components because of fracture of tibial extension(s).See x-rays.Update:aug 21, 2017 patient revised (b)(6)2017.The reported event has been evaluated and will be monitored.Depuy considers the investigation closed at this time.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 ORTHOPAEDICS, INC.1818910; 700 orthopaedic drive; warsaw IN 46582
• MDR Report Key: 6864261
• Report Number: 1818910-2017-24567
• Device Sequence Number: 496245
• Product Code: JWH
• UDI-Device Identifier: 10603295179788
• UDI-Public: 10603295179788
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K870730
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Explanted Year: 2017
• Reporter Type: Manufacturer
• Report Source: foreign,health professional
• Initial Reporter Occupation: Health Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 08/15/2017

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: 627115
• Device Lot Number: PO205
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 08/15/2017
• Supplement Date Received by Manufacturer: 12/14/2017
• Initial Report FDA Received Date: 09/14/2017
• Supplement Report FDA Received Date: 12/19/2017
• 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: 81 YR