MEDULLARY PLUG W/OUT DRAIN 4 N/A 00000003204

MAUDE Adverse Event Report

MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a foreign,literature report with the FDA on 2016-10-28 for MEDULLARY PLUG W/OUT DRAIN 4 N/A 00000003204 manufactured by Zimmer Gmbh.

Event Text Entries

[58600628] The manufacturer did not receive devices or x-rays for review. The product has been discarded. Where lot numbers were received for the devices, the device history records were reviewed and found to be conforming. A cause for this specific event cannot be ascertained from the information provided. Should additional information become available and an investigation result be available, that changes this assessment, an amended medical device report will be submitted. Zimmer? S reference number of this file is (b)(4).
Patient Sequence No: 1, Text Type: N, H10


[58600629] The event was reported in a journal article. It was reported that the patient was implanted an medullary plug w/out drain 4 on (b)(6) 2007 on the left side. The surgical technique was followed. On (b)(6) 2008 the patient underwent a periprothetic debridement and mobilization the parts were left in situ. The patient was revised on (b)(6) 2009 due to periprosthetic infection with staphylococcus aureus. Journal article: "reverse total shoulder arthroplasty for failed open reduction and internal fixation of fractures of the proximal humerus", f. Grubhofer, k. Wieser, d. C. Meyer, s. Catanzaro, k. Sch? Rholz, c. Gerber. J shoulder elbow surg. 2016 aug 9.
Patient Sequence No: 1, Text Type: D, B5


[64451070] Additional: if follow-up, what type? Update: date received by mfr. Type of reports, evaluation codes, additional mfr narrative. No trend identified. The device manufacturing quality records indicate that the released components met all requirements to perform as intended. Event description (event details, per) - event summary: in article it is mentioned that a (b)(6) female patient underwent revision surgery 9 months after index surgery due to periprosthetic staphylococcus aureus infection. The additional information received report implantation date (b)(6) 2007, had periprosthetic debridement and mobilization on (b)(6) 2008 and that the patient underwent revision surgery on (b)(6) 2009. The surgeon assures that all complications were not related to the implanted products. Review of received data - the surgical report of implantation dated (b)(6) 2007 was received for review. No conspicuousness. -the surgical notes of debridement and mobilization dated (b)(6) 2008 is available. Patient was experiencing pain and reduced range of motion, until the left shoulder has loss the functionality. It is reported that in (b)(6) 2007 the patient had a punction which showed no bacterial growing. The surgery was performed to free the joint from scar tissue. Intraoperative no evidence of infection. -the surgical report of revision dated (b)(6) 2009 was received for review. The notes states that the patient has pain and the revision it's performed to convert the inverse shoulder back to a hemi-prosthesis in order to relief patient's pain without expecting any functional improvement. Intraoperatively, scar tissue is observed and yellowish-whitish membranes are found below the inlay and the head. The membranes as well as the implants are sent for bacteriological evaluation. No other conspicuousness. -additionally, the notes of a visit dated (b)(6) 2009 are available. The notes states that the bacteriological tests evidenced of drug resistant bacteria. The patient needed to get antibiotics to combats the infection. No product was returned to zimmer biomet for in-depth analysis as they have been discarded at hospital after the removal. Root cause analysis the gamma sterilization specification of the device certifies the suitability of sterilization. The irradiation certificate of the affected lots have been reviewed and were found to be according to specification. Therefore, it can be excluded that an unsterile device caused the infection. Moreover, no trend on infection has been observed for this product family. Therefore, it is highly unlikely that a disadvantageous product design favored or contributed to the infection. However, the ifu for endoprosthesis d011500200 states that? Early or late infections? Are? Possible consequences of an implant? And should be considered when implanting zimmer biomet devices. There was no evidence of infection until the bacterial test performed on the materials of revision surgery on (b)(6) 2009. Additionally, the surgeon assures that all complications were not related to the implanted products. Conclusion summary in article it is mentioned that a (b)(6) female patient underwent revision surgery 9 months after index surgery due to periprosthetic staphylococcus aureus infection. However, the received surgical notes are in contrast with the event reported in the journal article. The surgical notes state that the patient underwent a surgery after 9 months (on (b)(6) 2008), but the implants were left in situ. 12 month after this surgery, on (b)(6) 2009, there was a conversion of the inverse shoulder back to a hemi-prosthesis (with product explantation/exchange). The gamma sterilization specification of the device certifies the suitability of sterilization. The irradiation certificate of the affected lots have been reviewed and were found to be according to specification. Therefore, it can be excluded that an unsterile device caused the infection. Moreover, no trend on infection has been observed for this product family. Therefore, it is highly unlikely that a disadvantageous product design favored or contributed to the infection. However, the ifu for endoprosthesis d011500200 states that? Early or late infections? Are? Possible consequences of an implant? And should be considered when implanting zimmer biomet devices. There was no evidence of infection until the bacterial test performed on the materials of revision surgery on (b)(6) 2009. Additionally, the surgeon assures that all complications were not related to the implanted products. An exact root cause could not be determined. The need for corrective measures is not indicated and zimmer (b)(4) considers this case as closed. (b)(4).
Patient Sequence No: 1, Text Type: N, H10


MAUDE Entry Details

Report Number0009613350-2016-01311
MDR Report Key6063025
Report SourceFOREIGN,LITERATURE
Date Received2016-10-28
Date of Report2016-10-06
Date of Event2009-03-19
Date Mfgr Received2016-12-30
Device Manufacturer Date2007-04-24
Date Added to Maude2016-10-28
Event Key0
Report Source CodeManufacturer report
Manufacturer LinkY
Number of Patients in Event0
Adverse Event Flag3
Product Problem Flag3
Reprocessed and Reused Flag3
Health Professional3
Initial Report to FDA3
Report to FDA3
Event Location3
Manufacturer ContactMR. KEVIN ESCAPULE
Manufacturer Street1800 WEST CENTER STREET
Manufacturer CityWARSAW IN 46580
Manufacturer CountryUS
Manufacturer Postal46580
Manufacturer Phone8006136131
Manufacturer G1ZIMMER GMBH
Manufacturer StreetSULZER ALLEE 8 SULZER INDUSTRIE PARK
Manufacturer CityWINTERTHUR 8404
Manufacturer CountrySZ
Manufacturer Postal Code8404
Single Use3
Previous Use Code3
Removal Correction NumberN/A
Event Type3
Type of Report3

Device Details

Brand NameMEDULLARY PLUG W/OUT DRAIN 4
Generic NamePOLYETHYLENE MEDULLARY PLUG
Product CodeLZN
Date Received2016-10-28
Model NumberN/A
Catalog Number00000003204
Lot Number2382741
ID Number00889024417441
Device Expiration Date2012-04-30
OperatorLAY USER/PATIENT
Device AvailabilityN
Device AgeDA
Device Eval'ed by MfgrR
Device Sequence No1
Device Event Key0
ManufacturerZIMMER GMBH
Manufacturer AddressSULZER ALLEE 8 SULZER INDUSTRIE PARK WINTERTHUR 8404 SZ 8404


Patients

Patient NumberTreatmentOutcomeDate
101. Hospitalization; 2. Required No Informationntervention 2016-10-28

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