MAUDE Adverse Event Report: MICROPORT ORTHOPEDICS INC. CONSERVE A-CLASS BFH HEAD SHORT NECK 50MM; HIP COMPONENT

Model Number	38AM5004
Health Effect - Clinical Code	Metal Related Pathology (4530)
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
See investigation attached.
Event or Problem Description
Allegedly, the patient was revised due to metallosis (no pseudotumor) and the failure of modular neck at the neck/stem junction taper (neck broken).
Event or Problem Description
Allegedly, the patient was revised due to failure of the modular neck at the neck/stem junction taper (fractured neck).The revision operative notes also lists, "moderate metallosis (no pseudotumor)" as an intraoperative finding.
Additional Manufacturer Narrative
Updated incident description.All previous information including the investigation remain the same.

• Brand Name: CONSERVE A-CLASS BFH HEAD SHORT NECK 50MM
• Common Device Name: HIP COMPONENT
• Manufacturer (Section D): MICROPORT ORTHOPEDICS INC.; 5677 airline rd.; arlington TN 38002
• MDR Report Key: 11585808
• Report Number: 3010536692-2021-00180
• Device Sequence Number: 14291943
• Product Code: KWA
• UDI-Device Identifier: M68438AM50041
• UDI-Public: M68438AM50041
• Combination Product (Y/N): N
• Initial Reporter State: SC
• Initial Reporter Country: US
• PMA/510(K) Number: K021349
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2005
• Device Explanted Year: 2021
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 05/27/2021

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: Other
• Device Model Number: 38AM5004
• Device Catalogue Number: 38AM5004
• Device Lot Number: 065229812
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 03/12/2021
• Initial Date Received by Manufacturer: 03/12/2021
• Supplement Date Received by Manufacturer: 03/12/2021
• Initial Report FDA Received Date: 03/29/2021
• Supplement Report FDA Received Date: 05/27/2021
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 66 YR