MAUDE Adverse Event Report: MEDACTA INTERNATIONAL SA AMISTEM H COATED STD STEM SIZE 7; HIP UNCEMENTED STEM

Model Number	01.18.137
Health Effect - Clinical Code	Inadequate Osseointegration (2646)
Date of Event	11/02/2020
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Batch review performed on (b)(6) 2020: lot 140017: 60 items manufactured and released on 07-apr-2014.Expiration date: 2019-02-28.No anomalies found related to the problem.To date, 56 items of the same lot have been already sold without any other similar reported event since 2016.
Event or Problem Description
The patient came in reporting pain due to a loose stem.The cause of the loose stem is unknown.The surgeon revised the stem and head with competitor products and revised the versafitcup dm liner hc 52/28 with a versafitcup dm liner hc 52/28 4 years and 11 months after primary.The surgery was completed successfully.

• Brand Name: AMISTEM H COATED STD STEM SIZE 7
• Common Device Name: HIP UNCEMENTED STEM
• Manufacturer (Section D): MEDACTA INTERNATIONAL SA; strada regina; castel san pietro, 6874 ; SZ 6874
• MDR Report Key: 10926484
• Report Number: 3005180920-2020-00848
• Device Sequence Number: 716145
• Product Code: LZO
• UDI-Device Identifier: 07630030804137
• UDI-Public: 07630030804137
• Combination Product (Y/N): N
• Initial Reporter State: IL
• Initial Reporter Country: US
• PMA/510(K) Number: K093944
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2015
• Device Explanted Year: 2020
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 12/01/2020

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 Expiration Date: 02/28/2019
• Device Model Number: 01.18.137
• Device Catalogue Number: 01.18.137
• Device Lot Number: 140017
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 12/01/2020
• Initial Report FDA Received Date: 12/01/2020
• 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: Required Intervention
• Patient Age: 87 YR
• Patient Weight: 63