MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS INC US PINN MAR +4 10D 36IDX54OD; PINNACLE HIP SYSTEM : HIP POLY ACETABULAR LINERS

Model Number	1219-36-154
Medical Device Problem Code	Device Dislodged or Dislocated (2923)
Health Effect - Clinical Code	Joint Dislocation (2374)
Date of Event	12/29/2020
Type of Reportable Event	Serious Injury
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 patient underwent a partial revision hip surgery due to multiple dislocations.Patient's 36x54 +4/10 degree poly liner and 36 mm -2 femoral headball were removed and replaced with a pinnacle dual mobility 54x47 liner and 28 mm ts +8.5 ceramic femoral head for stability.No further information is available.No surgical delay noted.Doi: approximately 10 years ago, dor: (b)(6) 2020, affected side: right hip.
Additional Manufacturer Narrative
Product complaint #(b)(4).Investigation summary - no device associated with this report was received for examination.A singular x-ray image provided is of poor quality.It does not depict a dislocation event.The information received will be retained for potential series investigations if triggered by trend analysis or other events within the quality system.Depuy considers the investigation closed.Should additional information be received, the information will be reviewed, and the investigation will be re-opened as necessary.Device history lot - a device history record (mre) review, was not possible because the required lot code was not provided.

• Brand Name: PINN MAR +4 10D 36IDX54OD
• Common Device Name: PINNACLE HIP SYSTEM : HIP POLY ACETABULAR LINERS
• Manufacturer (Section D): DEPUY ORTHOPAEDICS INC US; 700 orthopaedic drive; warsaw IN 46581 0988
• MDR Report Key: 11147267
• Report Number: 1818910-2021-00774
• Device Sequence Number: 631256
• Product Code: LPH
• UDI-Device Identifier: 10603295014584
• UDI-Public: 10603295014584
• Combination Product (Y/N): N
• Initial Reporter State: VA
• Initial Reporter Country: US
• PMA/510(K) Number: K033273
• 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,health
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 12/29/2020

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?: Yes
• Operator of Device: Health Professional
• Device Model Number: 1219-36-154
• Device Catalogue Number: 121936154
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 12/29/2020
• Supplement Date Received by Manufacturer: 12/29/2020; 02/10/2021
• Initial Report FDA Received Date: 01/11/2021
• Supplement Report FDA Received Date: 01/18/2021; 02/10/2021
• 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: ARTICULEZE M HEAD 36MM -2.; PINN MAR +4 10D 36IDX54OD.; ARTICULEZE M HEAD 36 MM -2; PINN MAR +4 10D 36IDX54OD
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 54 YR