MAUDE Adverse Event Report: SMITH & NEPHEW, INC. LGN CEMENT STEM12MMX120MM STRT; PROSTHE, KNEE, PATELLOFEM, SEMI-CONS, CEMEN, POLY/METAL/POLY

Catalog Number	71424184
Medical Device Problem Code	Insufficient Device Problem Information (3190)
Health Effect - Clinical Code	Unspecified Infection (1930)
Date of Event	03/21/2019
Type of Reportable Event	Serious Injury
Event or Problem Description
It was reported that a revision surgery was performed due to infection and all parts were removed.Patient received antibiotic spacer.
Additional Manufacturer Narrative
The associated complaint devices were not returned.The clinical/medical team concluded, it has been communicated that no clinical documents are available.Therefore, no thorough clinical assessment of the reported issue can be rendered.Should additional information be provided, the clinical medical investigation task will be reopened.A review of the production documentation for the corresponding products did not reveal any deviation from the standard manufacturing processes.A review of complaint history for the listed parts revealed no prior complaints for the listed batches.Product was sterilized according to sterilization release documentation from quality control.Without the actual product involved, our investigation cannot proceed.If the device or new information is received in the future, this complaint can be re-opened.
Additional Manufacturer Narrative
Correction:brand name,common device name,procode.

• Brand Name: LGN CEMENT STEM12MMX120MM STRT
• Common Device Name: PROSTHE, KNEE, PATELLOFEM, SEMI-CONS, CEMEN, POLY/METAL/POLY
• Manufacturer (Section D): SMITH & NEPHEW, INC.; 1450 brooks road; memphis TN 38116
• MDR Report Key: 8497835
• Report Number: 1020279-2019-01490
• Device Sequence Number: 1780872
• Product Code: JWH
• UDI-Device Identifier: 00885556645390
• UDI-Public: 00885556645390
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K043440
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2018
• Device Explanted Year: 2019
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 10/18/2019

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 Catalogue Number: 71424184
• Device Lot Number: 17CAP0146A
• Initial Date Received by Manufacturer: 03/21/2019
• Supplement Date Received by Manufacturer: 03/21/2019; 03/21/2019
• Initial Report FDA Received Date: 04/09/2019
• Supplement Report FDA Received Date: 10/18/2019; 10/18/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: PART NUMBER 71424227 / LOT NUMBER 17JM14302
• Outcome Attributed to Adverse Event: Hospitalization; Required Intervention