BEUDAMED
    FDA Adverse Event Injury Summary report: N

    MBT CEM KEEL TIB TRAY SZ2.5

    MDR report key: 2896511 · Received January 4, 2013

    Report

    Report Number
    1818910-2013-10245
    Event Type
    Injury
    Date Received
    January 4, 2013
    Date of Event
    December 19, 2012
    Report Date
    December 19, 2012
    Manufacturer
    DEPUY IRELAND ¿ REG. # 9616671
    Product Code
    NJL
    PMA / PMN Number
    PP830055
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    ID, US
    Reporter Occupation
    PHYSICIAN

    Narratives

    Additional Manufacturer Narrative · 1

    THIS COMPLAINT IS STILL UNDER INVESTIGATION. DEPUY WILL NOTIFY THE FDA OF THE RESULTS OF THIS INVESTIGATION ONCE IT HAS BEEN COMPLETED.

    Additional Manufacturer Narrative · 1

    THE DEVICE ASSOCIATED WITH THIS REPORT WAS NOT RETURNED. A COMPLAINT DATABASE SEARCH FINDS NO OTHER REPORTED INCIDENTS AGAINST THE PROVIDED PRODUCT AND LOT COMBINATION SINCE ITS RELEASE FOR DISTRIBUTION. REQUESTS FOR ADDITIONAL INVESTIGATIONAL INPUTS WERE MADE IN ACCORDANCE WITH WI-7915 APPENDIX A; REV. C. NO ADDITIONAL INFORMATION WAS OBTAINED. THE INVESTIGATION COULD NOT DRAW ANY CONCLUSIONS REGARDING THE REPORTED EVENT. BASED ON THE INABILITY TO DETERMINE A ROOT CAUSE, THE NEED FOR CORRECTIVE ACTION WAS NOT INDICATED. DEPUY CONSIDERS THE INVESTIGATION CLOSED AT THIS TIME. SHOULD THE PRODUCT AND/OR ADDITIONAL INFORMATION BE RECEIVED, THE INVESTIGATION WILL BE RE-OPENED.

    Description of Event or Problem · 1

    PATIENT WAS REVISED TO ADDRESS SUDDEN KNEE PAIN AND LOOSENING OF THE TIBIAL TRAY AT THE CEMENT/IMPLANT INTERFACE. DEPUY CEMENT WAS USED AT THE TIME OF ORIGINAL IMPLANTATION. IT WAS REPORTED THAT THE SURGEON BELIEVED THAT HE HAD PUNCHED THE TIBIA FOR A 2.5 TRAY AND DECIDED TO RECUT THE TIBIA EITHER VARUS OR VALGUS. HE THEN REPUNCHED. HE DID NOT CEMENT THE KEEL HOLE, AND HE BELIEVES THIS ALLOWED THE TRAY TO TOGGLE

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    4987 MBT CEM KEEL TIB TRAY SZ2.5 TIBIAL KNEE PROSTHESIS NJL DEPUY IRELAND ¿ REG. # 9616671 3174346

    Patients

    Seq Age Sex Outcome Treatment
    1 48 YR Required Intervention