MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS, INC.1818910 SIGMA HP UNI INS SZ3 11MM LMRL; KNEE TIBIAL BEARING/INSERT

Catalog Number	102453311
Medical Device Problem Code	Misconnection (1399)
Health Effect - Clinical Code	No Information (3190)
Date of Event	10/13/2017
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
Synergy form states that unicompartmental knee replacement was performed.On insertion of the tibial insert it was noted that the locking mechanism did not lock the liner.Surgeon impacted liner but liner did not lock.The liner was then removed and a size 3, 10 mm liner was then implanted and the locking mechanism worked.Surgeon has questioned the locking mechanism and would like it to be checked.
Additional Manufacturer Narrative
If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.This complaint is still under investigation.Depuy will notify the fda of the results of this investigation once it has been completed.
Additional Manufacturer Narrative
Examination of the returned device revealed evidence confirming the reported event.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.

• Brand Name: SIGMA HP UNI INS SZ3 11MM LMRL
• Common Device Name: KNEE TIBIAL BEARING/INSERT
• Manufacturer (Section D): DEPUY ORTHOPAEDICS, INC.1818910; 700 orthopaedic drive; warsaw IN 46582
• MDR Report Key: 7040774
• Report Number: 1818910-2017-29245
• Device Sequence Number: 13653088
• Product Code: HRY
• UDI-Device Identifier: 10603295002574
• UDI-Public: 10603295002574
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K070267
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Health Professional
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 11/28/2017

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: 102453311
• Device Lot Number: H59015
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 11/28/2017
• Initial Date Received by Manufacturer: 10/20/2017
• Supplement Date Received by Manufacturer: 11/28/2017; 12/13/2017
• Initial Report FDA Received Date: 11/17/2017
• Supplement Report FDA Received Date: 12/01/2017; 12/13/2017
• 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