MAUDE Adverse Event Report: MICROPORT ORTHOPEDICS INC. DYNASTY A-CLASS 36MM STD GROUP D CROSSLINKED POL; HIP COMPONENT

Model Number	DLXPGD36
Health Effect - Clinical Code	Unspecified Infection (1930)
Type of Reportable Event	Serious Injury
Event or Problem Description
Allegedly, cup loosened and causing weight bearing pain.Blood pathology indicated infection.All prosthesis removed (eto was preformed on femoral stem) and antibiotic cement spacer implanted.Photo's of x-ray and removed implants were provided.

• Brand Name: DYNASTY A-CLASS 36MM STD GROUP D CROSSLINKED POL
• Common Device Name: HIP COMPONENT
• Manufacturer (Section D): MICROPORT ORTHOPEDICS INC.; 5677 airline rd.; arlington TN 38002
• MDR Report Key: 11398294
• Report Number: 3010536692-2021-00118
• Device Sequence Number: 4532262
• Product Code: JDI
• UDI-Device Identifier: M684DLXPGD361
• UDI-Public: M684DLXPGD361
• Combination Product (Y/N): N
• Initial Reporter State: NJ
• Initial Reporter Country: US
• PMA/510(K) Number: K061547
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2017
• Device Explanted Year: 2021
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: distributor
• Initial Reporter Occupation: Physician
• Type of Report: Initial

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?: No
• Operator of Device: Health Professional
• Device Model Number: DLXPGD36
• Device Catalogue Number: DLXPGD36
• Device Lot Number: 1690366
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 02/18/2021
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 02/18/2021
• Initial Report FDA Received Date: 03/02/2021
• Patient Sequence Number: 1
• Patient Age: 63 YR