MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS INC US SELF CENT HIP 40X28 RUST; HEMI HIP IMPLANT : HIP ACETABULAR POLY/METAL HEMI

Model Number 1035-40-000

Device Problem Device Dislodged or Dislocated (2923)

Patient Problems Fall (1848); Joint Dislocation (2374)

Event Date 02/04/2021

Event Type  Injury  

Manufacturer Narrative

Product complaint #: (b)(4).If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.Corrected phone number.

Event Description

It was indicated that patient had an antibiotic spacer placed on 1/16/21.Patient fell and dislocated his hip.He also broke the acetaular cup spacer away from his bone during this fall.A new acetabular component was cemented in place and the neck length was upsized.Patient is a non compliant patient per doctor.Loosening interface is bone to cement and the cement manufacturer is unknown doi: (b)(6) 2021, dor: (b)(6) 2021.

Manufacturer Narrative

Product complaint # (b)(4).Investigation summary : 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: SELF CENT HIP 40X28 RUST
• Type of Device: HEMI HIP IMPLANT : HIP ACETABULAR POLY/METAL HEMI
• Manufacturer (Section D): DEPUY ORTHOPAEDICS INC US; 700 orthopaedic drive; warsaw IN 46581 0988
• MDR Report Key: 11359214
• MDR Text Key: 232961143
• Report Number: 1818910-2021-03562
• Device Sequence Number: 1
• Product Code: KWY
• UDI-Device Identifier: 10603295003304
• UDI-Public: 10603295003304
• Combination Product (y/n): N
• PMA/PMN Number: K812672
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative,health
• Type of Report: Initial,Followup
• Report Date: 02/04/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 02/22/2021
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: 1035-40-000
• Device Catalogue Number: 103540000
• Device Lot Number: J8374K
• Was Device Available for Evaluation?: No
• Date Manufacturer Received: 03/17/2021
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1
• Treatment: ALTRX +4 NEUT 40IDX64OD; ARTICUL/EZE BALL 28 +1.5 GR; SELF CENT HIP 40X28 RUST; UNKNOWN BONE CEMENT; ALTRX +4 NEUT 40IDX64OD; ARTICUL/EZE BALL 28 +1.5 GR; SELF CENT HIP 40X28 RUST; UNKNOWN BONE CEMENT
• Patient Outcome(s): Required Intervention