MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS INC US SUMMIT ANGLED INSERTER; HIP INSTRUMENTS : IMPACTORS

Model Number	2570-05-125
Medical Device Problem Code	Device-Device Incompatibility (2919)
Health Effect - Clinical Code	Insufficient Information (4580)
Date of Event	11/16/2020
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Product complaint # (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 kincise stem impactor doesn't fit into kincise gun.Offset summit impactor cold welded to stem implant.When the doctor disengaged the impactor the stem came out with it.Please send both replacements sos to (b)(6) office.Surgery delayed for 1 minute.No additional information.
Additional Manufacturer Narrative
Product complaint # (b)(4).Investigation summary: the device associated with this report was not returned.The investigation could not verify or identify any product contribution to the reported event with the information provided.Depuy synthes considers the investigation closed at this time.Should additional information be received, the information will be reviewed and the investigation may be re-opened as necessary.

• Brand Name: SUMMIT ANGLED INSERTER
• Common Device Name: HIP INSTRUMENTS : IMPACTORS
• Manufacturer (Section D): DEPUY ORTHOPAEDICS INC US; 700 orthopaedic drive; warsaw IN 46581 0988
• MDR Report Key: 10958577
• Report Number: 1818910-2020-26315
• Device Sequence Number: 583648
• Product Code: HWR
• UDI-Device Identifier: 10603295143222
• UDI-Public: 10603295143222
• Combination Product (Y/N): N
• Initial Reporter State: CA
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• 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): 11/16/2020

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Model Number: 2570-05-125
• Device Catalogue Number: 257005125
• Initial Date Received by Manufacturer: 11/16/2020
• Supplement Date Received by Manufacturer: 01/13/2021
• Initial Report FDA Received Date: 12/07/2020
• Supplement Report FDA Received Date: 01/13/2021
• Patient Sequence Number: 1