MAUDE Adverse Event Report: ENCORE MEDICAL L.P. TIBIAL INSERT; INSERT, ULTRA CONGRUENT SIZE10 11MM CM

Model Number	380-11-510
Health Effect - Clinical Code	No Code Available (3191)
Date of Event	09/09/2019
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The reason for this revision surgery was reported as instability.The previous surgery and the surgery detailed in this event occurred 13.8 years apart.The healthcare professional indicated there was no significant adverse event.There was no delay in surgery and another suitable device was available for use.The revision surgery was completed as intended.The device was discarded and not made available to djo surgical for examination.A review of the device history record show that the reported component used in the previous surgery, when released for use, met design and manufacturing requirements.There were no nonconforming material reports associated with the product that may have contributed to the reported event.The device was verified to have gone through an acceptable sterilization process and was within its expiration date at the time of the previous surgery.Customer complaint history of the reported device showed no present trends or on-going issues that are needing a review.The root cause of this complaint was a revision surgery due to instability.There were no findings during this evaluation that indicate the reported devices were defective.No information was submitted with the complaint regarding pre-existing conditions of the patient or any activities the patient was involved in that may have contributed to the event.There are multiple factors that may contribute to an event that are outside of the control of djo surgical.
Event or Problem Description
Revision surgery - due to instability.

• Brand Name: TIBIAL INSERT
• Common Device Name: INSERT, ULTRA CONGRUENT SIZE10 11MM CM
• Manufacturer (Section D): ENCORE MEDICAL L.P.; 9800 metric blvd; austin TX 78758 5445
• MDR Report Key: 9376782
• Report Number: 1644408-2019-01213
• Device Sequence Number: 16708779
• Product Code: JWH
• UDI-Device Identifier: 00888912117166
• UDI-Public: (01)00888912117166
• Combination Product (Y/N): N
• Initial Reporter State: AZ
• Initial Reporter Country: US
• PMA/510(K) Number: K963028
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2005
• Device Explanted Year: 2019
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 11/26/2019

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: 07/28/2008
• Device Model Number: 380-11-510
• Device Catalogue Number: 380-11-510
• Device Lot Number: 899581
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 10/24/2019
• Initial Report FDA Received Date: 11/26/2019
• 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: Required Intervention
• Patient Age: 71 YR