MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS INC US ALTRX +4 NEUT 40IDX58OD; PINNACLE HIP SYSTEM : HIP POLY ACETABULAR LINERS

Catalog Number 122140458

Device Problem Adverse Event Without Identified Device or Use Problem (2993)

Patient Problems Pulmonary Embolism (1498); Hypersensitivity/Allergic reaction (1907); Pain (1994); Thrombosis (2100); Ambulation Difficulties (2544); No Code Available (3191)

Event Date 01/01/2020

Event Type  Injury  

Manufacturer Narrative

(b)(4).If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.Investigation summary: no device associated with this report was received for examination.The provided x-ray images could not confirm the reported allegations.The root cause could not be determined.The information received will be retained for potential series investigations if triggered by trend analysis or other events within the quality system.Depuy considers the investigation closed.Should additional information be received, the information will be reviewed, and the investigation will be re-opened as necessary.

Event Description

It was reported that there was an allergic reaction to hip replacement and they are trying to find out what kind of metals are in patient hip.Records indicate the patient reports persistent pain and had recurring postoperative deep vein thrombosis and pulmonary embolism.Doi: (b)(6) 2016.Dor: unknown.Affected side: right hip.

Manufacturer Narrative

Product complaint # (b)(4).This report is being submitted pursuant to the provisions of 21 cfr, part 803.This report may be based on information prior to the required reporting date.This report does not reflect a conclusion by depuy synthes joint reconstruction, or its employees that the report constitutes an admission that the product, depuy synthes joint reconstruction, or its employees caused or contributed to the potential event described in this report.If information is obtained that was not available for the initial report, a follow-up report will be filed as appropriate.

Manufacturer Narrative

Product complaint # (b)(4).This report is being submitted pursuant to the provisions of 21 cfr, part 803.This report may be based on information which has not been investigated or verified prior to the required reporting date.This report does not reflect a conclusion by depuy synthes joint reconstruction, or its employees that the report constitutes an admission that the product, depuy synthes joint reconstruction, or its employees caused or contributed to the potential event described in this report.H10 additional narrative: if information is obtained that was not available for the initial report, a follow-up report will be filed as appropriate.

Manufacturer Narrative

Product complaint # (b)(4).Investigation summary : no device associated with this report was received for examination.The information received will be retained for potential series investigations if triggered by trend analysis, post market surveillance, or other events within the quality system.Depuy considers the investigation closed.Should additional information be received, the information will be reviewed and the investigation will be re-opened as necessary.Device history lot : the product investigation found no evidence suspecting an error in the manufacturing or material that would be a contributing factor in the reported allegation(s).A manufacturing records evaluation (mre) was not performed.

• Brand Name: ALTRX +4 NEUT 40IDX58OD
• Type of Device: PINNACLE HIP SYSTEM : HIP POLY ACETABULAR LINERS
• Manufacturer (Section D): DEPUY ORTHOPAEDICS INC US; 700 orthopaedic drive; warsaw IN 46581 0988
• Manufacturer (Section G): DEPUY ORTHOPAEDICS, INC. 1818910; 700 orthopaedic dr.; warsaw IN 46581 0988
• Manufacturer Contact: kara ditty-bovard ; 700 orthopaedic drive; warsaw, IN 46581-0988 ; 6107428552
• MDR Report Key: 10437993
• MDR Text Key: 203883879
• Report Number: 1818910-2020-18546
• Device Sequence Number: 1
• Product Code: LPH
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K062148
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Consumer
• Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup,Followup,Followup
• Report Date: 08/12/2020

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
• Device Operator: Health Professional
• Device Expiration Date: 12/31/2020
• Device Catalogue Number: 122140458
• Device Lot Number: 730891
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Initial Date Manufacturer Received: 08/12/2020
• Initial Date FDA Received: 08/21/2020
• Supplement Dates Manufacturer Received: 10/13/2020; 10/13/2020; 12/02/2021
• Supplement Dates FDA Received: 10/15/2020; 10/26/2020; 12/06/2021
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Date Device Manufactured: 01/26/2016
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1
• Treatment: 11/13 S-ROM 40MM M SPEC+0; 18D LARGE PROXIMAL FEMORAL SLEEVE; 40 MM +0 METAL FEMORAL HEAD FOR 11/13 TAPER; 58 X 40 +4 NEUTRAL ALTRX POLYETHYLENE LINER; 58-MM PINNACLE SECTOR CUP WITH GRIPTION; APEX HOLE ELIM POSITIVE STOP; PINN SECTOR W/GRIPTION 58MM; S-ROM 18 X 13 +12 STEM; S-ROM*SLEEVE PRX ZTT, 16D-LRG; SROM STM STD 36+12L 13X18; 18D LARGE PROXIMAL FEMORAL SLEEVE; 40 MM +0 METAL FEMORAL HEAD FOR 11/13 TAPER; 58 X 40 +4 NEUTRAL ALTRX POLYETHYLENE LINER; 58-MM PINNACLE SECTOR CUP WITH GRIPTION; S-ROM 18 X 13 +12 STEM
• Patient Outcome(s): Required Intervention
• Patient Age: 53 YR
• Patient Weight: 110 KG