MAUDE Adverse Event Report: MEDACTA INTERNATIONAL SA STEM: AMISTEM COLLARED 01.18.232 STEM COLLARED HA COATED STD STEM SIZE 2; HIP STEM COLLARED

Model Number 01.18.232

Device Problems Loose or Intermittent Connection (1371); Appropriate Term/Code Not Available (3191)

Patient Problem Insufficient Information (4580)

Event Date 04/04/2022

Event Type  Injury  

Manufacturer Narrative

Batch review performed on 06 april 2022 lot 147176: (b)(4).Expiration date: 2019-12-31.No anomalies found related to the problem.(b)(4).

Event Description

The patient came in reporting pain due to a loose stem and the cause is unknown.The surgeon revised the stem, head and liner almost 6 years and 7 months after primary.The surgery was completed successfully.

• Brand Name: STEM: AMISTEM COLLARED 01.18.232 STEM COLLARED HA COATED STD STEM SIZE 2
• Type of Device: HIP STEM COLLARED
• Manufacturer (Section D): MEDACTA INTERNATIONAL SA; strada regina; castel san pietro, 6874 ; SZ 6874
• Manufacturer (Section G): MEDACTA INTERNATIONAL SA; strada regina; castel san pietro, 6874 ; SZ 6874
• Manufacturer Contact: stefano baj ; strada regina; castel san pietro, switzerland 6874 ; SZ 6874
• MDR Report Key: 14287036
• MDR Text Key: 290769417
• Report Number: 3005180920-2022-00320
• Device Sequence Number: 1
• Product Code: LZO
• UDI-Device Identifier: 07630030804571
• UDI-Public: 07630030804571
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K121011
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Company Representative
• Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date: 05/04/2022

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 05/05/2022
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Operator: Health Professional
• Device Expiration Date: 12/31/2019
• Device Model Number: 01.18.232
• Device Catalogue Number: 01.18.232
• Device Lot Number: 147176
• Was Device Available for Evaluation?: No
• Date Manufacturer Received: 04/04/2022
• Was Device Evaluated by Manufacturer?: No
• Date Device Manufactured: 01/21/2015
• 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 Sex: Female