MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS INC US PINN MULTIHOLE W/GRIPTION 50MM; PINNACLE HIP SYSTEM : HIP METAL ACETABULAR CUPS

Model Number	1217-30-050
Medical Device Problem Code	Loss of Osseointegration (2408)
Health Effect - Clinical Codes	Pain (1994); Inadequate Osseointegration (2646); No Code Available (3191)
Date of Event	06/02/2020
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Product complaint # (b)(4).If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.
Event or Problem Description
The patient was revised to address painful loosening of acetabular components and augment at bone to implant interface.Doi: (b)(6) 2015, dor: (b)(6) 2020, affected side: left hip.
Additional 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.

• Brand Name: PINN MULTIHOLE W/GRIPTION 50MM
• Common Device Name: PINNACLE HIP SYSTEM : HIP METAL ACETABULAR CUPS
• Manufacturer (Section D): DEPUY ORTHOPAEDICS INC US; 700 orthopaedic drive; warsaw IN 46581 0988
• MDR Report Key: 10145673
• Report Number: 1818910-2020-13695
• Device Sequence Number: 3184769
• Product Code: LPH
• UDI-Device Identifier: 10603295009979
• UDI-Public: 10603295009979
• Combination Product (Y/N): N
• Initial Reporter State: TX
• Initial Reporter Country: US
• PMA/510(K) Number: K071784
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2015
• Device Explanted Year: 2020
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 06/02/2020

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?: Yes
• Operator of Device: Health Professional
• Device Model Number: 1217-30-050
• Device Catalogue Number: 121730050
• Device Lot Number: 614420
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 06/02/2020
• Supplement Date Received by Manufacturer: 07/24/2020
• Initial Report FDA Received Date: 06/11/2020
• Supplement Report FDA Received Date: 07/27/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: 5.5X45 MM GRIPTION TF STE SCREW.; 5.5X60 MM GRIPTION TF STE SCREW.; ALTRX +4 NEUT 32IDX50OD.; DELTA CER HEAD 12/14 32MM +5.; PINN CAN BONE SCREW 6.5 MMX15 MM.; PINN CAN BONE SCREW 6.5 MMX30 MM.; PINN CAN BONE SCREW 6.5 MMX45 MM.; PINN CAN BONE SCREW 6.5 MMX45 MM.; PINN GRIP TF REV AUGM 15X50/52.; PINNACLE BONE SCREW 25 MM.; 5.5X45 MM GRIPTION TF STE SCREW; 5.5X60 MM GRIPTION TF STE SCREW; ALTRX +4 NEUT 32IDX50OD; DELTA CER HEAD 12/14 32MM +5; PINN CAN BONE SCREW 6.5 MMX15 MM; PINN CAN BONE SCREW 6.5 MMX30 MM; PINN CAN BONE SCREW 6.5 MMX45 MM; PINN CAN BONE SCREW 6.5 MMX45 MM; PINN GRIP TF REV AUGM 15X50/52; PINNACLE BONE SCREW 25 MM
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 60 YR