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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: MEDACTA INTERNATIONAL SA TIBIAL INSERT FIXED SPHERE FLEX SIZE 5/17 MM L
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MEDACTA INTERNATIONAL SA TIBIAL INSERT FIXED SPHERE FLEX SIZE 5/17 MM L Back to Search Results
Catalog Number 02.12.0517FL
Health Effect - Clinical Code Unspecified Infection (1930)
Date of Event 04/18/2018
Type of Reportable Event Serious Injury
Additional Manufacturer Narrative
Batch review performed on 18 may 2018; lot 173783 : (b)(4) items manufactured and released on 14 march 2017 expiration date: 2022-10-26; no anomalies found related to the problem.To date, (b)(4) items of the same lot have been already sold without any similar reported event.
 
Event or Problem Description
Revision surgery performed due to signs of infection.The pathogen is unknown.The surgeon revised the poly.
 
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Brand Name
TIBIAL INSERT FIXED SPHERE FLEX SIZE 5/17 MM L
Common Device Name
TIBIAL INSERT FIXED
Manufacturer (Section D)
MEDACTA INTERNATIONAL SA
strada regina
castel san pietro, switzerland 6874
SZ  6874
MDR Report Key7525814
Report Number3005180920-2018-00345
Device Sequence Number13786421
Product Code JWH
UDI-Device Identifier07630030826856
UDI-Public07630030826856
Combination Product (Y/N)N
Initial Reporter StateIL
Initial Reporter CountryUS
PMA/510(K) Number
K121416
Number of Events Summarized1
Summary Report (Y/N)N
Device Implanted Year2018
Device Explanted Year2018
Reporter Type Manufacturer
Report Source other
Initial Reporter Occupation Other
Type of Report Initial
Report Date (Section B) 05/18/2018
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 Expiration Date10/26/2022
Device Catalogue Number02.12.0517FL
Device Lot Number173783
Was Device Available for Evaluation? No
Was the Report Sent to FDA? No
Type of Report(Section G)Thirty-Day
Initial Date Received by Manufacturer 04/20/2018
Initial Report FDA Received Date05/18/2018
Is This a Single-Use Device that was
Reprocessed and Reused on a Patient? (Y/N)		 No
Patient Sequence Number1
Outcome Attributed to Adverse Event Required Intervention;
Patient Age54 YR
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