MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS INC US DUR DYNAMIC LOCK RING 62 OR 74; DURALOC IMPLANT : HIP ACETABULAR AUGMENT

Model Number	1249-62-000
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	No Code Available (3191)
Date of Event	06/11/2020
Type of Reportable Event	Serious Injury
Additional 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 or Problem Description
It was reported that the patient's hip subluxed many times over the past couple of years, but last week it finally dislocated completely.They were able to reduce him but he decided to have it revised.No corrosion on the neck taper and head joint.Everything was well fixed.I do not have the exact date they were originally implanted in 2003.Doi: 2003.Dor: (b)(6) 2020; right side.
Additional Manufacturer Narrative
Product complaint # (b)(4).Investigation summary: no device associated with this report was received for examination.Review of the attached x-ray image could not confirm the reported allegation.The root cause could not be determined.The information received will be retained for potential series investigations if triggered by trend analysis 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: DUR DYNAMIC LOCK RING 62 OR 74
• Common Device Name: DURALOC IMPLANT : HIP ACETABULAR AUGMENT
• Manufacturer (Section D): DEPUY ORTHOPAEDICS INC US; 700 orthopaedic drive; warsaw IN 46581 0988
• MDR Report Key: 10191087
• Report Number: 1818910-2020-14368
• Device Sequence Number: 11517376
• Product Code: LPH
• UDI-Device Identifier: 10603295019817
• UDI-Public: 10603295019817
• Combination Product (Y/N): N
• Initial Reporter State: MI
• Initial Reporter Country: US
• PMA/510(K) Number: K951301
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• 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): 06/11/2020

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
• Operator of Device: Health Professional
• Device Model Number: 1249-62-000
• Device Catalogue Number: 124962000
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 06/11/2020
• Supplement Date Received by Manufacturer: 08/06/2020
• Initial Report FDA Received Date: 06/24/2020
• Supplement Report FDA Received Date: 08/07/2020
• 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: ARTICULEZE M 28MM 8.5; CANCELLOUS BONE SCREW 6.5X35MM; DUR MAR 10D LINER 28IDX62OD; DURALOC SECTOR SERIES 62OD; ARTICULEZE M 28MM 8.5; CANCELLOUS BONE SCREW 6.5X35MM; DUR MAR 10D LINER 28IDX62OD; DURALOC SECTOR SERIES 62OD
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 80 YR
• Patient Weight: 116