MAUDE Adverse Event Report: MEDACTA INTERNATIONAL SA GMK-REVISION FIXED TIBIAL INSERT SC SIZE 2/14MM; KNEE TIBIAL INSERT

Model Number	02.07.0214SCF
Health Effect - Clinical Code	Joint Disorder (2373)
Date of Event	02/17/2020
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Batch review performed on 21 february 2020: lot 185105: (b)(4) items manufactured and released on 04-sep-2018.Expiration date: 2023-08-22.No anomalies found related to the problem.To date, (b)(4) items of the same lot have been already sold without any other similar reported event.
Event or Problem Description
The patient had a primary knee surgery and was implanted with competitor products.The patient had a revision knee surgery on (b)(6) 2019 and was implanted with medacta hardware.On (b)(6) 2020, the patient came in complaining of pain due to laxity in the knee.The cause of the laxity is unknown.The surgeon revised the medacta insert semiconstrained 14mm s2 to a medacta insert semiconstrained 17mm s2.The surgery was completed successfully.

• Brand Name: GMK-REVISION FIXED TIBIAL INSERT SC SIZE 2/14MM
• Common Device Name: KNEE TIBIAL INSERT
• Manufacturer (Section D): MEDACTA INTERNATIONAL SA; strada regina; castel san pietro, 6874 ; SZ 6874
• MDR Report Key: 9834852
• Report Number: 3005180920-2020-00156
• Device Sequence Number: 1551442
• Product Code: JWH
• UDI-Device Identifier: 07630030816710
• UDI-Public: 07630030816710
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K103170
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2019
• Device Explanted Year: 2020
• Reporter Type: Manufacturer
• Report Source: other
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 03/16/2020

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: 08/22/2023
• Device Model Number: 02.07.0214SCF
• Device Catalogue Number: 02.07.0214SCF
• Device Lot Number: 185105
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 02/17/2020
• Initial Report FDA Received Date: 03/16/2020
• 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