MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS INC US S-ROM*PIN LOCK,5.0MM DIA; S-ROM HIP SYSTEM : HIP ACETABULAR AUGMENT

Model Number	55-0295
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Pain (1994); No Code Available (3191)
Date of Event	10/14/2020
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 had a right tha performed over 20 years ago with no information available about that surgery.On (b)(6) 2020.The patient had a right tha revision of the head and liner for poly wear reported in (b)(4).The patient received a rerevision to treat pain secondary to too much offset and leg length.This new surgeon wanted to removed the entire srom cup and put in a competitor dual mobility and needed to use my srom 11/13 taper heads.The surgeon removed the metal head, poly dial liner and locking pins, screw and cup.He implanted a competitor dual mobility head and used my 28mm +3 metal srom head.He was happy with the leg lengths and offset.Doi: (b)(6) 2020, dor: (b)(6) 2020, affected side: right hip.
Additional Manufacturer Narrative
Product complaint # (b)(4).Investigation summary: no device associated with this report was received for examination.A singular x-ray image was provided for review.There is nothing indicative of a product problem identified.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.

• Common Device Name: S-ROM HIP SYSTEM : HIP ACETABULAR AUGMENT
• Manufacturer (Section D): DEPUY ORTHOPAEDICS INC US; 700 orthopaedic drive; warsaw IN 46581 0988
• MDR Report Key: 10752663
• Report Number: 1818910-2020-23505
• Device Sequence Number: 19662569
• Product Code: JDI
• UDI-Device Identifier: 10603295175162
• UDI-Public: 10603295175162
• Combination Product (Y/N): N
• Initial Reporter State: WA
• Initial Reporter Country: US
• PMA/510(K) Number: K963206
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2020
• Device Explanted Year: 2020
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 10/14/2020

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: 55-0295
• Device Catalogue Number: 550295
• Device Lot Number: H60234
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 10/14/2020
• Supplement Date Received by Manufacturer: 11/25/2020
• Initial Report FDA Received Date: 10/28/2020
• Supplement Report FDA Received Date: 11/26/2020
• 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: S-ROM*HEAD FEMORAL COCR 32+6; S-ROM*PIN LOCK,5.0MM DIA; S-ROM*PIN LOCK,5.0MM DIA; SROM CUP L SERIES; SROM CUP SCREW UNKNOWN SIZE; SROM MAR LNR L 32MM+3MM 10 DEG; S-ROM*HEAD FEMORAL COCR 32+6; S-ROM*PIN LOCK,5.0MM DIA; S-ROM*PIN LOCK,5.0MM DIA; SROM CUP L SERIES; SROM CUP SCREW UNKNOWN SIZE; SROM MAR LNR L 32MM+3MM 10 DEG
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 70 YR
• Patient Weight: 79