MAUDE Adverse Event Report: CONFORMIS, INC. ITOTAL PS; TOTAL KNEE REPLACEMENT SYSTEM

Model Number	TPS111111101
Health Effect - Clinical Code	No Code Available (3191)
Date of Event	11/01/2017
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
A revision surgery is planned to exchange the poly insert.Reason for revision is unknown at this time.Review of the device history record indicates that the device was manufactured to specification.
Event or Problem Description
A revision surgery is planned to exchange the poly insert.Reason for revision is unknown at this time.
Additional Manufacturer Narrative
It was reported that during pt session the patient's knee locked up in extension.Since then, there has been a medial "clicking" noise through the full range of motion.The surgeon opened the knee and cleaned up the scar tissue and still the issue persisted.A revision surgery is planned to exchange the poly insert.Review of the device history record indicates the device was manufactured to specification.
Event or Problem Description
It was reported that during pt session the patient's knee locked up in extension.Since then, there has been a medial "clicking" noise through the full range of motion.The surgeon opened the knee and cleaned up the scar tissue and still the issue persisted.A revision surgery is planned to exchange the poly insert.

• Brand Name: ITOTAL PS
• Common Device Name: TOTAL KNEE REPLACEMENT SYSTEM
• Manufacturer (Section D): CONFORMIS, INC.; 600 technology park drive; billerica MA 01821
• MDR Report Key: 7048112
• Report Number: 3004153240-2017-00254
• Device Sequence Number: 1450592
• Product Code: JWH
• UDI-Device Identifier: M572TPS1111111011
• UDI-Public: +M572TPS1111111011
• Combination Product (Y/N): N
• Initial Reporter State: CA
• Initial Reporter Country: US
• PMA/510(K) Number: K153217
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2016
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 12/01/2017

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: Physician
• Device Expiration Date: 07/31/2016
• Device Model Number: TPS111111101
• Device Catalogue Number: TPS-111-1111
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Initial Date Received by Manufacturer: 11/10/2017
• Supplement Date Received by Manufacturer: 11/10/2017
• Initial Report FDA Received Date: 11/21/2017
• Supplement Report FDA Received Date: 12/01/2017
• 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: 59 YR