MAUDE Adverse Event Report: SMITH & NEPHEW, INC. LGN POS FEM WDG 5MM SZ5-6 LNG; PROSTHESIS, HIP, SEMI-CONSTRAINED, METAL/POLYMER, CEMENTED

Model Number	71421805
Medical Device Problem Code	Incomplete or Inadequate Connection (4037)
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	09/14/2020
Type of Reportable Event	Serious Injury
Event or Problem Description
It was reported that during an unknown procedure, the lgn pos fem wdg 5mm sz5-6 lng would not tighten down completely even with the screw all the way tightened.This resulted in the augment having to be cemented.The patient condition is unknown.
Additional Manufacturer Narrative
The device, used in treatment, was not returned for evaluation and the reported event could not be confirmed.The clinical/medical investigation concluded that per complaint details, ¿the augment wouldn¿t tighten down completely¿ during 2 separate procedures this week which resulted in a modified surgical procedure by ¿cementing the augment on both times¿.Reportedly, the surgeon performs many revisions and has not experienced this issue in the past.Responses to requested information/documentation was not provided; therefore, the root cause of the reported event could not be concluded.The patient impact beyond the modified surgical procedure could not be determined as the patient outcomes were not provided, although no patient injury or surgical delay was alleged.No further medical assessment is warranted at this time.Should additional clinically relevant documentation/information become available, the clinical/medical task may be re-evaluated.A complaint history review found related failures; this failure mode will be monitored for future complaints and assessed for any necessary corrective actions.A review of the manufacturing records did not reveal a manufacturing abnormality that could have caused or contributed to the reported incident.At this time, we have no reason to suspect that the product failed to meet any product specifications at the time of manufacture.A review of the risk management file and instructions for use documents revealed this failure mode and potential harm was previously identified.Possible causes could include but not limited to surgical technique used, size of device or user/procedural variance.Based on this investigation, the need for corrective action is not indicated.Without the return of the actual product involved or product information, our investigation could not proceed.Should the device or additional information be received, the complaint will be reopened.No further investigation is warranted for this complaint; however, we will continue to monitor for future complaints and investigate as necessary.We consider this investigation closed.

• Brand Name: LGN POS FEM WDG 5MM SZ5-6 LNG
• Common Device Name: PROSTHESIS, HIP, SEMI-CONSTRAINED, METAL/POLYMER, CEMENTED
• Manufacturer (Section D): SMITH & NEPHEW, INC.; 1450 brooks rd.; memphis TN 38116
• MDR Report Key: 10673601
• Report Number: 1020279-2020-05363
• Device Sequence Number: 14134951
• Product Code: JDI
• UDI-Device Identifier: 03596010545398
• UDI-Public: 03596010545398
• Combination Product (Y/N): N
• Initial Reporter State: PA
• Initial Reporter Country: US
• PMA/510(K) Number: K052792
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,user f
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 06/30/2021

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: 71421805
• Device Catalogue Number: 71421805
• Device Lot Number: 19JSM0200
• Initial Date Received by Manufacturer: 09/14/2020
• Supplement Date Received by Manufacturer: 06/30/2021
• Initial Report FDA Received Date: 10/13/2020
• Supplement Report FDA Received Date: 06/30/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Hospitalization; Required Intervention