MAUDE Adverse Event Report: MICROPORT ORTHOPEDICS INC. ADVANCE® CANAL FILLING STEM EXTENSION 16MM X 100MM; KNEE COMPONENT

Model Number	KSP15100
Medical Device Problem Code	Loose or Intermittent Connection (1371)
Health Effect - Clinical Code	No Information (3190)
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
This event will be updated when investigation is complete.
Event or Problem Description
Allegedly the patient was revised due to component are loose.All components came out.

• Brand Name: ADVANCE® CANAL FILLING STEM EXTENSION 16MM X 100MM
• Common Device Name: KNEE COMPONENT
• Manufacturer (Section D): MICROPORT ORTHOPEDICS INC.; 5677 airline rd.; arlington TN 38002
• MDR Report Key: 8922869
• Report Number: 3010536692-2019-01012
• Device Sequence Number: 11294588
• Product Code: JWH
• UDI-Device Identifier: M684KSP151001
• UDI-Public: M684KSP151001
• Combination Product (Y/N): N
• Initial Reporter State: UT
• Initial Reporter Country: US
• PMA/510(K) Number: K973524
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Explanted Year: 2019
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 08/22/2019

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: Other
• Device Model Number: KSP15100
• Device Catalogue Number: KSP15100
• Device Lot Number: 1417087
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 07/23/2019
• Initial Date Received by Manufacturer: 07/23/2019
• Supplement Date Received by Manufacturer: 07/23/2019
• Initial Report FDA Received Date: 08/22/2019
• Supplement Report FDA Received Date: 02/17/2020
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention