MAUDE Adverse Event Report: ENCORE MEDICAL L.P CONSTRAINED LINER HIP; LINER, ACETABULAR, FMP CONSTRAINED 28XMP8

Model Number	436-28-000
Health Effect - Clinical Code	Unspecified Infection (1930)
Date of Event	01/19/2021
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
Third revision surgery - due to infection and dislocation.
Additional Manufacturer Narrative
See g1 - new contact for encore medical l.P.Additional narrative: the reason for this revision surgery was due to an infection and dislocation.The previous surgery and the surgery detailed in this event occurred 6 months apart.The in vivo time for the proximal body is 7.6 months, from a more previous revision surgery.No information was submitted with the complaint regarding pre-existing conditions of the patient or any activities the patient was involved in that may have contributed to the infection and dislocation or inhibited the patient's immune system.The healthcare professional indicated there was no delay in surgery and another suitable device was available for use.The revision surgery was completed as intended.The device was not made available to djo surgical for examination.A review of the device history record show that the reported component used in the previous surgery, when released for use, met design and manufacturing requirements.There were no nonconforming material reports associated with the product that may have contributed to the reported event.The device was verified to have gone through an acceptable sterilization process and was within its expiration date at the time of the previous surgery.Customer complaint history of the reported device 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 an infection and dislocation.There were no findings during this evaluation that indicate that the reported device was defective or had a direct connection with the patient's infection.There are multiple factors that may contribute to an infection that are outside of the control of djo surgical.There are no indications of a product or process issue affecting implant safety or effectiveness.Additional reporting on this event will be provided as a supplemental report to this document if it becomes available.

• Brand Name: CONSTRAINED LINER HIP
• Common Device Name: LINER, ACETABULAR, FMP CONSTRAINED 28XMP8
• Manufacturer (Section D): ENCORE MEDICAL L.P; 9800 metric blvd; austin,tx 78758-5445
• MDR Report Key: 11332473
• Report Number: 1644408-2021-00086
• Device Sequence Number: 1034862
• Product Code: KWZ
• UDI-Device Identifier: 00888912085663
• UDI-Public: (01)00888912085663
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K023794
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2020
• Device Explanted Year: 2021
• 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
• Report Date (Section B): 04/16/2021

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 Expiration Date: 07/06/2021
• Device Model Number: 436-28-000
• Device Catalogue Number: 436-28-008
• Device Lot Number: 500C1008
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 01/19/2021
• Supplement Date Received by Manufacturer: 03/17/2021
• Initial Report FDA Received Date: 02/16/2021
• Supplement Report FDA Received Date: 04/16/2021
• 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: 436-28-000, LOT 496C1074; 436-28-008 LOT 500C1008; 495-01-085 LOT 549U1022; 495-01-085, LOT 549U1022; 497-28-105 LOT 632C1182; 497-28-105, LOT 632C1182; 436-28-008 LOT 500C1008; 495-01-085 LOT 549U1022; 497-28-105 LOT 632C1182
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 63 YR