MAUDE Adverse Event Report: MICROPORT ORTHOPEDICS INC. CONSERVE A-CLASS BFH HEAD MEDIUM NECK 44MM; HIP COMPONENT

Model Number	38AM4400
Health Effect - Clinical Code	Unequal Limb Length (4534)
Type of Reportable Event	Serious Injury
Event or Problem Description
Allegedly, cup was improperly positioned.Leg length difference.Our neck and head came out along w/the shell (w/o cup cutters).Tjo cup, screws (2), liner and head used with our neck.Cultures taken.Bmi 24.8 right hip.Component not revised: pyrd0004 profemur raz stem lot 067426983.

• Brand Name: CONSERVE A-CLASS BFH HEAD MEDIUM NECK 44MM
• Common Device Name: HIP COMPONENT
• Manufacturer (Section D): MICROPORT ORTHOPEDICS INC.; 5677 airline rd.; arlington TN 38002
• MDR Report Key: 11116209
• Report Number: 3010536692-2021-00002
• Device Sequence Number: 19731926
• Product Code: KWA
• UDI-Device Identifier: M68438AM44001
• UDI-Public: M68438AM44001
• Combination Product (Y/N): N
• Initial Reporter State: UT
• Initial Reporter Country: US
• PMA/510(K) Number: K021349
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2007
• Device Explanted Year: 2020
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: distributor
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 01/05/2021

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: 38AM4400
• Device Catalogue Number: 38AM4400
• Device Lot Number: 077444899
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 12/22/2020
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 12/22/2020
• Initial Report FDA Received Date: 01/05/2021
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 66 YR
• Patient Weight: 64