MAUDE Adverse Event Report: DEPUY IRELAND - 9616671 ACTIS COLLARED HIGH SIZE 9; HIP FEMORAL STEM

Model Number 1010-12-090

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

Patient Problem Appropriate Clinical Signs, Symptoms, Conditions Term / Code Not Available (4581)

Event Date 11/12/2020

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.

Event Description

It was reported that the patient developed infection, components listed below were removed but the cup and 3 screws remained.Doi:(b)(6) 2020, dor: (b)(6) 2020, right hip.

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 sterilization manufacturing or material that would be a contributing factor in the reported allegation(s).A manufacturing records evaluation (mre) was not performed.H10 additional narrative: added: d4 (lot) and g4 corrected: d2b.

• Brand Name: ACTIS COLLARED HIGH SIZE 9
• Type of Device: HIP FEMORAL STEM
• Manufacturer (Section D): DEPUY IRELAND - 9616671; loughbeg ringaskiddy co.; cork ; EI
• MDR Report Key: 10923800
• MDR Text Key: 218937260
• Report Number: 1818910-2020-25714
• Device Sequence Number: 1
• Product Code: KWL
• UDI-Device Identifier: 10603295380610
• UDI-Public: 10603295380610
• Combination Product (y/n): N
• PMA/PMN Number: K150862
• 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: 11/12/2020

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 Model Number: 1010-12-090
• Device Catalogue Number: 101012090
• Device Lot Number: J8722U
• Was Device Available for Evaluation?: No
• Initial Date Manufacturer Received: 11/12/2020
• Initial Date FDA Received: 11/30/2020
• Supplement Dates Manufacturer Received: 01/05/2021
• Supplement Dates FDA Received: 01/06/2021
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1
• Treatment: ALTRX NEUT 36IDX58OD.; ARTICULEZE M HEAD 36MM +1.5.; UNK HIP BONE SCREW.; UNK HIP BONE SCREW.; UNK HIP BONE SCREW.; UNKNOWN HIP ACETABULAR CUP.; ALTRX NEUT 36IDX58OD; ARTICULEZE M HEAD 36MM +1.5; UNK HIP BONE SCREW; UNK HIP BONE SCREW; UNK HIP BONE SCREW; UNKNOWN HIP ACETABULAR CUP
• Patient Outcome(s): Required Intervention
• Patient Age: 73 YR