MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS INC US S-ROM*HEAD FEMORAL COCR 28+0; HIP IMPLANT FEMORAL HEAD

Model Number 52-2028

Device Problem Device Dislodged or Dislocated (2923)

Patient Problem Fall (1848)

Event Date 12/20/2022

Event Type  Injury  

Manufacturer Narrative

Product complaint # (b)(4).Gtin: product was marked for gudid exclusion.Unique identifier( udi) : udi/gtin information is not applicable.Product is no longer marketed.Depuy synthes is submitting this report pursuant to the provisions of 21 cfr, part 803.This report may be based on information which depuy synthes has not been able to investigate or verify prior to the required reporting date.This report does not reflect a conclusion by fda, depuy synthes or its employees that the report constitutes an admission that the device, depuy synthes, or its employees caused or contributed to the potential event described in this report.If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.

Event Description

Revision of srom/stryker mdm total hip replacement - patient had a fall and dislocated, caused a disassociation of the dual mobility head and liner.Surgeon went in, washed out hip , replaced depuy srom head and stryker mdm liner.Left total hip - original surgery completed by dr in (b)(6) 2022, specifics unknown.

Event Description

Additional information received stated that there was no surgical delay reported.

Manufacturer Narrative

Product complaint # (b)(4).This report is being submitted pursuant to the provisions of 21 cfr, part 803.This report may be based on information which has not been investigated or verified prior to the required reporting date.This report does not reflect a conclusion by depuy synthes joint reconstruction, or its employees that the report constitutes an admission that the product, depuy synthes joint reconstruction, or its employees caused or contributed to the potential event described in this report.If information is obtained that was not available for the initial report, a follow-up report will be filed as appropriate.

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 : a manufacturing record evaluation (nc search) was performed for the finished device product code 522028, lot number 9536077 and no non-conformances / manufacturing irregularities were identified.

• Type of Device: HIP IMPLANT FEMORAL HEAD
• Manufacturer (Section D): DEPUY ORTHOPAEDICS INC US; 700 orthopaedic drive; warsaw IN 46581 0988
• Manufacturer (Section G): DEPUY ORTHOPAEDICS, INC. 1818910; 700 orthopaedic dr.; warsaw IN 46581 0988
• Manufacturer Contact: kate karberg ; 700 orthopaedic dr.; warsaw, IN 46581-0988 ; 3035526892
• MDR Report Key: 16130665
• MDR Text Key: 306997058
• Report Number: 1818910-2023-00893
• Device Sequence Number: 1
• Product Code: JDI
• UDI-Device Identifier: 10603295170792
• UDI-Public: 10603295170792
• Combination Product (y/n): N
• Reporter Country Code: AS
• PMA/PMN Number: K920317
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Foreign,Health Professional,Company Representative
• Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup,Followup
• Report Date: 01/10/2023

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?: Yes
• Device Operator: Health Professional
• Device Model Number: 52-2028
• Device Catalogue Number: 522028
• Device Lot Number: 9536077
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Initial Date Manufacturer Received: 12/21/2022
• Initial Date FDA Received: 01/10/2023
• Supplement Dates Manufacturer Received: 02/01/2023; 02/18/2023
• Supplement Dates FDA Received: 02/08/2023; 02/20/2023
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Date Device Manufactured: 06/05/2020
• 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
• Treatment: S-ROM HEAD FEMORAL COCR 28+9; STRYKER MDM LINER( COMPETITOR PRODUCT ); UNKNOWN HIP ACETABULAR CUP
• Patient Outcome(s): Required Intervention
• Patient Sex: Male