MAUDE Adverse Event Report: ENCORE MEDICAL L.P. EMPOWR HIP; EMPOWR ACETABULAR SYSTEM, LINER, 10° HOODED, HXE+, 40G

Model Number	940-00-030
Health Effect - Clinical Code	Unspecified Infection (1930)
Date of Event	10/15/2020
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Additional reporting on this event will be provided as a supplemental report to this document if it becomes available.
Event or Problem Description
Revision surgery - due to an infection.
Additional Manufacturer Narrative
Manufacturer narrative: the reason for this revision surgery was reported as infection.The previous surgery and the surgery detailed in this event occurred 30 days apart.The healthcare professional indicated there was no delay in surgery and another suitable device was available for use.The revision surgery was completed as intended.The devices were disposed of at the hospital and not made available to djo surgical for examination.A review of the device history records (dhr) show that the reported components used in the previous surgery, when released for use, met design and manufacturing requirements.There were no non-conforming material reports (ncmr) associated with the products that may have contributed to the reported event.The devices were verified to have gone through an acceptable sterilization process and were within its expiration date at the time of the previous surgery.The root cause of this complaint was reported as an infection.There were no findings during this evaluation that indicate the reported devices were the source or had a direct connection with the patient's infection.No information was submitted with the complaint regarding pre-existing conditions of the patient or any activities the patient was involved in that may have contributed to the possible infection or inhibited the patient's immune system.Due to the short time between the original surgery and the revision, it is possible that the infection was acquired in the hospital (nosocomial).It is also possible that the patient was not compliant with post surgical instructions.There are multiple factors that may contribute to an infection that are outside the control of djo surgical.There are no indications of a product or process issue affecting implant safety or effectiveness.Additional reporting on this event will be provided as a supplemental report to this document if it becomes available.
Additional Manufacturer Narrative
Corrected data: d.4.Lot number and expiration date.H.4.Device manufacture date.Additional reporting on this event will be provided as a supplemental report to this document if it becomes available.

• Brand Name: EMPOWR HIP
• Common Device Name: EMPOWR ACETABULAR SYSTEM, LINER, 10° HOODED, HXE+, 40G
• Manufacturer (Section D): ENCORE MEDICAL L.P.; 9800 metric blvd; austin, tx 78758-5445
• MDR Report Key: 10836319
• Report Number: 1644408-2020-01020
• Device Sequence Number: 19560324
• Product Code: LPH
• UDI-Device Identifier: 00190446293446
• UDI-Public: (01)00190446293446
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K190057
• 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
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 09/10/2021

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 Expiration Date: 06/15/2025
• Device Model Number: 940-00-030
• Device Catalogue Number: 942-01-40G
• Device Lot Number: 628Z1012
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 10/15/2020
• Supplement Date Received by Manufacturer: 01/22/2021; 04/21/2021
• Initial Report FDA Received Date: 11/13/2020
• Supplement Report FDA Received Date: 02/19/2021; 09/10/2021
• 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: 400-04-400 LOT 884B1105; 400-04-400 LOT 884B1105; 400-05-000 LOT 886B1188; 400-05-000 LOT 886B1188; 940-00-030 LOT 147Z1029; 940-02-54G LOT 801Z1039; 940-02-54G LOT 801Z1039; 942-01-40G LOT 628Z1014; 400-04-400 LOT 884B1105; 400-05-000 LOT 886B1188; 940-02-54G LOT 801Z1039; 942-01-40G LOT 628Z1014
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 70 YR