MAUDE Adverse Event Report: ENCORE MEDICAL L.P. EXPRT REVISION HIP; EXPRT REVISION HIP, DISTAL STEM, 14X210

Model Number	495-14-210
Health Effect - Clinical Code	Insufficient Information (4580)
Date of Event	03/05/2021
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
Second revision surgery - exprt stem subsided.Pulled out exprt stem and put in a new one.
Additional Manufacturer Narrative
Manufacturer narrative: the reason for this revision surgery was due to subsided stem.The previous surgery and the surgery detailed in this event occurred 8 months and 2 weeks apart.There was no information submitted with this complaint about any patient activities, accidents, or medical contraindications that may have contributed to the reported event.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 disposed of at the hospital and not made available to djo surgical for examination.A review of the device history record (dhr) shows that the reported components used in the previous surgery, when released for use, met design and manufacturing requirements.There was no non-conforming material report (ncmr) 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 compliant was a revision surgery due to subsided stem.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 event.There are multiple factors that may also contribute to an event that are outside the control of djo surgical such as poor bone density, patient bone deterioration, inadequate soft tissue support, patient activities or trauma.There were no findings during this evaluation that indicate the reported device was defective.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: EXPRT REVISION HIP
• Common Device Name: EXPRT REVISION HIP, DISTAL STEM, 14X210
• Manufacturer (Section D): ENCORE MEDICAL L.P.; 9800 metric blvd.; austin TX 78758 5445
• MDR Report Key: 11605192
• Report Number: 1644408-2021-00235
• Device Sequence Number: 3262985
• Product Code: KWZ
• UDI-Device Identifier: 00190446153931
• UDI-Public: (01)00190446153931
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K163497
• 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): 05/22/2021

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: 12/03/2025
• Device Model Number: 495-14-210
• Device Catalogue Number: 495-14-210
• Device Lot Number: 595U1011
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 03/05/2021
• Supplement Date Received by Manufacturer: 04/23/2021
• Initial Report FDA Received Date: 04/01/2021
• Supplement Report FDA Received Date: 05/22/2021
• 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: 400-03-401, LOT 870B1160.; 495-00-065, LOT 539U1087.
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 69 YR