MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS INC US MODULAR CATHCART BALL 53MM OD; HEMI HIP IMPLANT : HIP ACETABULAR METAL HEMI

Model Number	1363-53-000
Medical Device Problem Code	Device Dislodged or Dislocated (2923)
Health Effect - Clinical Codes	Joint Dislocation (2374); No Code Available (3191)
Date of Event	07/22/2020
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 patient came to er dislocated.Surgeon explanted current 53 unipolar head ball and +5 tapered sleeve and began trialing with + 5 28 mm and 53 bipolar head ball without luck of stability.He then trialed with +8.5 28mm head ball and still was dissatisfied with stability.He decided to explant summit stem (8std) and implant 8 hi summit stem with + 5 28mm head ball with a dual mobility competitor mdm cup.Surgeon stated he was displeased with depuy¿s ability to provide a dual mobility pinnacle implant.Original implant date unknown.Doi: unknown, 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: MODULAR CATHCART BALL 53MM OD
• Common Device Name: HEMI HIP IMPLANT : HIP ACETABULAR METAL HEMI
• Manufacturer (Section D): DEPUY ORTHOPAEDICS INC US; 700 orthopaedic drive; warsaw IN 46581 0988
• MDR Report Key: 10362425
• Report Number: 1818910-2020-17461
• Device Sequence Number: 13690849
• Product Code: LZY
• UDI-Device Identifier: 10603295032854
• UDI-Public: 10603295032854
• Combination Product (Y/N): N
• Initial Reporter State: MI
• Initial Reporter Country: US
• 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): 07/22/2020

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: 1363-53-000
• Device Catalogue Number: 136353000
• Device Lot Number: J0523K
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 07/22/2020
• Supplement Date Received by Manufacturer: 09/14/2020
• Initial Report FDA Received Date: 08/04/2020
• Supplement Report FDA Received Date: 09/14/2020
• 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: SUMMIT POR TAPER SZ8 STD OFF; TAPERED SPACER ARTICUL/EZE +5; SUMMIT POR TAPER SZ8 STD OFF; TAPERED SPACER ARTICUL/EZE +5
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 85 YR