MAUDE Adverse Event Report: SMITH & NEPHEW, INC. JOURNEY TIBIA BASE NP LT SZ 7; PRSTHSIS,KNEE,PATELLOFMOROTIBIAL,SMI-CNSTRAIND,CMNTD,POLYMR/MTAL/POLYMR

Catalog Number	74022227
Medical Device Problem Code	Insufficient Device Problem Information (3190)
Health Effect - Clinical Code	Injury (2348)
Date of Event	11/21/2018
Type of Reportable Event	Serious Injury
Event or Problem Description
It was reported that a revision surgery was performed.Patient presented with metallosis, joint was inflamed, soft tissue had a black colour.The surgeon revised the knee, took out the implants and replaced them.
Additional Manufacturer Narrative
The associated complaint devices were not returned.A review of complaint history did not reveal additional complaints for the listed batches.A review of the manufacturing records did not reveal a manufacturing abnormality that could have caused or contributed to the reported incident.The clinical / medical investigation concluded that, since no supporting clinical documentation has been provided for review, the reported findings cannot be confirmed.Without the supporting lab/pathology results, imaging, and/or the analysis of the explanted components, the source cannot be confirmed and it cannot be concluded that the reported clinical reactions were associated with a mal-performance of the implant.The patient impact beyond the reported symptoms, the intra-op findings with suspected titanium allergy, and the revision surgery with an expected post-operative rehabilitative phase cannot be concluded.Without the actual product involved, our investigation cannot proceed.If the devices or new information is received in the future, these complaints can be re-opened.No further actions are being taken at this time.We consider this investigation closed.

• Brand Name: JOURNEY TIBIA BASE NP LT SZ 7
• Common Device Name: PRSTHSIS,KNEE,PATELLOFMOROTIBIAL,SMI-CNSTRAIND,CMNTD,POLYMR/MTAL/POLYMR
• Manufacturer (Section D): SMITH & NEPHEW, INC.; 1450 brooks road; memphis TN 38116
• MDR Report Key: 8175823
• Report Number: 1020279-2018-02825
• Device Sequence Number: 2178552
• Product Code: JWH
• UDI-Device Identifier: 03596010554406
• UDI-Public: 03596010554406
• Combination Product (Y/N): N
• Initial Reporter Country: SF
• PMA/510(K) Number: K042515
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Explanted Year: 2018
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 05/30/2019

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 Date: 10/29/2020
• Device Catalogue Number: 74022227
• Device Lot Number: 10LM00305
• Initial Date Received by Manufacturer: 11/22/2018
• Supplement Date Received by Manufacturer: 11/22/2018
• Initial Report FDA Received Date: 12/18/2018
• Supplement Report FDA Received Date: 05/30/2019
• 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: Other; Required Intervention