MAUDE Adverse Event Report: DEPUY IRELAND - 9616671 LCS HP FEM NOTCH IMPACTOR; IMPACTORS

Catalog Number	950501219
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	11/03/2017
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
(b)(4).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
Surgeon: dr.(b)(6).Procedure: total knee replacement.During implanting of definitive lcs femoral (un-cemented) prosthesis - which requires significant impaction force - the black plastic impaction head of the notch impactor broke away from the metal body.All components retrieved - copious lovage attended to in case any debris remaining.But none noted.Action taken: tibial impactor utilised.Femoral component was fully seated using this tool.No ae to patient.A 1 minute delay to procedure.Female patient (b)(6), aged (b)(6), dob (b)(6).
Additional Manufacturer Narrative
Product complaint: (b)(4).Investigation summary: examination of the returned device confirms the reported event.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. .

• Brand Name: LCS HP FEM NOTCH IMPACTOR
• Common Device Name: IMPACTORS
• Manufacturer (Section D): DEPUY IRELAND - 9616671; loughbeg ringaskiddy co; cork ; EI
• MDR Report Key: 7070198
• Report Number: 1818910-2017-50386
• Device Sequence Number: 1004665
• Product Code: HWA
• UDI-Device Identifier: 10603295225263
• UDI-Public: 10603295225263
• Combination Product (Y/N): N
• Initial Reporter Country: AS
• 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): 11/03/2017

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Catalogue Number: 950501219
• Device Lot Number: PG1108
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 03/01/2018
• Initial Date Received by Manufacturer: 11/03/2017
• Supplement Date Received by Manufacturer: 03/13/2018; 04/06/2018
• Initial Report FDA Received Date: 11/30/2017
• Supplement Report FDA Received Date: 03/20/2018; 04/09/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 64 YR