MAUDE Adverse Event Report: ENCORE MEDICAL L.P. X-ALT HIP; LINER, ACETABULAR, 20 DH, HXL/FMP, 36MM ID 56MM CUP OD, MP9

Model Number 933-36-256

Device Problem Metal Shedding Debris (1804)

Patient Problems Pain (1994); No Code Available (3191)

Event Date 09/12/2017

Event Type  Injury  

Event Description

Revision surgery - due to the patient having significant metallosis and pain.

Manufacturer Narrative

The reason for this revision surgery was the patient was having significant metalosis and pain.The in-vivo length of patient service for the implant was 3.9 years.There is no information in this complaint about any patient injuries, activities, or accidents that may have contributed to the need for this revision surgery.There are no reported pre-existing patient health conditions.The healthcare professional indicated there was no delay in surgery and another suitable device was available for use.The revision surgery was completed as intended.The device was not released by the hospital and not made available to djo surgical for examination.A review of the implant device history records (dhr) shows that the reported component used in the previous surgery met design and manufacturing requirements.There were no non-conforming material reports (ncmrs) associated with the product that may have contributed to the event.The device was within its expiration date at the time of use during the previous surgery.Customer complaint history of the reported device showed no present trends or on-going issues that are in need of review.This event is deemed to be non-product related.The root cause of this complaint was a revision surgery due to the metallosis and pain.There are multiple factors that may contribute to the event that are outside the control of djo surgical are increased toxic levels in the body, patient behavior and activities or trauma.No additional information was submitted with the complaint regarding pre-existing conditions of the patient or any activities that may have contributed to the event and hence a definitive root cause cannot be determined.Inventory containment is not required as there are no indications of a product or process issue affecting implant safety or effectiveness.

• Brand Name: X-ALT HIP
• Type of Device: LINER, ACETABULAR, 20 DH, HXL/FMP, 36MM ID 56MM CUP OD, MP9
• Manufacturer (Section D): ENCORE MEDICAL L.P.; 9800 metric blvd.; austin TX 78758 5445
• Manufacturer (Section G): ENCORE MEDICAL L.P.; 9800 metric blvd.; austin TX 78758 5445
• Manufacturer Contact: teffany hutto ; 9800 metric blvd.; austin, TX 78758-5445
• MDR Report Key: 6941438
• MDR Text Key: 89179168
• Report Number: 1644408-2017-00861
• Device Sequence Number: 1
• Product Code: OQG
• UDI-Device Identifier: 00888912100632
• UDI-Public: (01)00888912100632
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K130365
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative
• Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date: 11/14/2017

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: 04/30/2017
• Device Model Number: 933-36-256
• Device Catalogue Number: 933-36-256
• Device Lot Number: 774F1011
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Was the Report Sent to FDA?: No
• Initial Date Manufacturer Received: 09/12/2017
• Initial Date FDA Received: 10/11/2017
• Supplement Dates Manufacturer Received: 10/27/2017
• Supplement Dates FDA Received: 11/14/2017
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Date Device Manufactured: 04/11/2013
• 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
• Patient Outcome(s): Required Intervention
• Patient Age: 78 YR