MAUDE Adverse Event Report: ENCORE MEDICAL L.P BIPOLAR HIP; SHELL, BIPOLAR, MODULAR, ENCORE, SIZE44

Model Number	497-28-000
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	11/03/2020
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 - revision/ conversion of a bipolar hip to a total due to instability.
Additional Manufacturer Narrative
Corrected data: see section d1., d2., d4., d10., & g4.Manufacturer narrative: the reason for this revision surgery was reported as instability.The actual length of in-vivo for the items listed is unknown as the original surgery date was not provided or could be established.The healthcare professional indicated there was significant adverse event to the patient.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 hospital and not made available to djo surgical for examination.This investigation is limited in scope as only partial information was provided to djo surgical.The revised items was not returned for examination and the lot numbers was not provided.To adequately investigate this event, the part and lot numbers are necessary.If this information is submitted at a future date, this investigation will be re-evaluated.Customer complaint history of the reported items showed no present trends or on-going issues that are needing a review.The root cause of this complaint was a revision surgery due to instability.There was no information submitted with this complaint about any patient activities, accidents, or medical contraindications that may have contributed to the reported event.The surgeon performed this revision to remedy the patient's condition.This complaint will be closed pending receipt of additional information.No further action is deemed necessary at this time.Additional reporting on this event will be provided as a supplemental report to this document if it becomes available.
Additional Manufacturer Narrative
Manufacturer narrative: the reason for this revision surgery was reported as instability.The actual length of in-vivo for the items listed is unknown as the original surgery date was not provided or could be established.The healthcare professional indicated there was significant adverse event to the patient.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 hospital and not made available to djo surgical for examination.This investigation is limited in scope as only partial information was provided to djo surgical.The revised items were not returned for examination and the lot numbers were not provided.To adequately investigate this event, lot numbers are necessary.Given the limited information, a search for an invoice (of the previous surgery) could not be conducted, therefore; the items removed could not be identified.If this information is submitted at a future date, this investigation will be re-evaluated.Customer complaint history of the reported items showed no present trends or on-going issues that are needing a review.There was no information submitted with this complaint about any patient activities, accidents, or medical contraindications that may have contributed to the reported event.The surgeon performed this revision to remedy the patient's condition.This complaint will be closed pending receipt of additional information.No further action is deemed necessary at this time.Additional reporting on this event will be provided as a supplemental report to this document if it becomes available.

• Brand Name: BIPOLAR HIP
• Common Device Name: SHELL, BIPOLAR, MODULAR, ENCORE, SIZE44
• Manufacturer (Section D): ENCORE MEDICAL L.P; 9800 metric blvd; austin,tx 78758-5445
• MDR Report Key: 10928550
• Report Number: 1644408-2020-01108
• Device Sequence Number: 4611721
• Product Code: KWY
• UDI-Device Identifier: 00888912087254
• UDI-Public: (01)00888912087254
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K953510
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• 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): 07/23/2021

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: 497-28-000
• Device Catalogue Number: 412-02-044
• Device Lot Number: UNKNOWN
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 11/03/2020
• Supplement Date Received by Manufacturer: 02/05/2021; 04/05/2021
• Initial Report FDA Received Date: 12/01/2020
• Supplement Report FDA Received Date: 03/05/2021; 07/23/2021
• 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: 412-02-044 LOT UNKNOWN; 497-28-000 LOT UNKNOWN; 412-02-044 LOT UNKNOWN
• Outcome Attributed to Adverse Event: Other; Required Intervention