MAUDE Adverse Event Report: MICROPORT ORTHOPEDICS INC. BIPOLAR ACETABULAR SHELL WITH DURAMER LINER; HIP COMPONENT

Model Number 3110-284400

Device Problem Disassembly (1168)

Patient Problem Pain (1994)

Event Type  Injury  

Manufacturer Narrative

This complaint will be updated once investigation is complete.Trends will be evaluated.

Event Description

Allegedly the surgeon performed bha surgery on (b)(6).The patient felt a pain in her hip and the surgeon found a stem rotation and a dissociation of the cup and head on (b)(6).The surgeon performed tha surgery on (b)(6).

• Brand Name: BIPOLAR ACETABULAR SHELL WITH DURAMER LINER
• Type of Device: HIP COMPONENT
• Manufacturer (Section D): MICROPORT ORTHOPEDICS INC.; 5677 airline rd.; arlington TN 38002
• Manufacturer (Section G): MICROPORT ORTHOPEDICS INC.; 5677 airline rd.; arlington TN 38002
• Manufacturer Contact: 5677 airline road; arlington, TN 38002 ; 9018674771
• MDR Report Key: 7660525
• MDR Text Key: 113087751
• Report Number: 3010536692-2018-00894
• Device Sequence Number: 1
• Product Code: KWY
• Combination Product (y/n): N
• PMA/PMN Number: K892398
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: health professional
• Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date: 07/03/2018

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 07/03/2018
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Operator: Other
• Device Model Number: 3110-284400
• Device Catalogue Number: 3110-284400
• Device Lot Number: 1738326
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 06/20/2018
• Date Manufacturer Received: 06/20/2018
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Is the Device Single Use?: Yes
• Type of Device Usage: N
• Patient Sequence Number: 1
• Patient Outcome(s): Required Intervention
• Patient Age: 86 YR
• Patient Weight: 35