MAUDE Adverse Event Report: ENCORE MEDICAL L.P EMPOWR HIP; EMPOWR ACETABULAR SYSTEM, LINER, 10° HOODED, HXE+, 36E

Model Number	942-01-36E
Health Effect - Clinical Code	Appropriate Clinical Signs, Symptoms and Conditions Term/Code Not Available (4581)
Date of Event	04/12/2021
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Additional reporting on this event will be provided as a supplemental report to this document as soon as it becomes available.
Event or Problem Description
Revision surgery - due to instability.
Additional Manufacturer Narrative
Manufacturer narrative: the reason for this revision surgery was reported as instability.The previous surgery and the surgery detailed in this event occurred 19 days apart.The healthcare professional indicated there was a significant adverse event to the patient.There was no delay in surgery and another suitable device was available for use.The revision surgery was completed as intended.The devices were disposed of at hospital and not made available to djo surgical for examination.A review of the device history records (dhr) show that the reported components used in the previous surgery, when released for use, met design and manufacturing requirements and showed no non-conforming material reports (ncmr) associated with the main component listed in the complaint.The devices were verified to have gone through an acceptable sterilization process and were within its expiration date at the time of the previous surgery.Customer complaint history of the reported devices 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 instability.There were no findings during this evaluation that indicate the reported devices were defective.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.Due to short time between previous and revision surgery, it is possible that the event may have occurred due to lack of post-operative care, patient noncompliance with medical instructions or incorrect implant selection, patient activities or trauma.There are multiple factors that may also contribute to an event that are outside 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: EMPOWR HIP
• Common Device Name: EMPOWR ACETABULAR SYSTEM, LINER, 10° HOODED, HXE+, 36E
• Manufacturer (Section D): ENCORE MEDICAL L.P; 9800 metric blvd; austin TX 78758 5445
• MDR Report Key: 11776855
• Report Number: 1644408-2021-00374
• Device Sequence Number: 4427744
• Product Code: LPH
• UDI-Device Identifier: 00190446309758
• UDI-Public: (01)00190446309758
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K190057
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2021
• 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): 06/03/2021

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?: Yes
• Operator of Device: Health Professional
• Device Expiration Date: 01/28/2025
• Device Model Number: 942-01-36E
• Device Catalogue Number: 942-01-36E
• Device Lot Number: 621Z1007
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 04/12/2021
• Supplement Date Received by Manufacturer: 05/11/2021
• Initial Report FDA Received Date: 05/05/2021
• Supplement Report FDA Received Date: 06/03/2021
• 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: 400-04-360 LOT 883B1218.; 400-04-360 LOT 883B1218.; 400-05-004 LOT 887B1093.; 400-05-004 LOT 887B1093.; 425-96-008 LOT 187R1207.; 425-96-008 LOT 487R1207.; 940-01-50E LOT 784Z1001.; 940-01-50E LOT 784Z1001.; 400-04-360 LOT 883B1218; 400-05-004 LOT 887B1093; 425-96-008 LOT 487R1207; 940-01-50E LOT 784Z1001
• Outcome Attributed to Adverse Event: Other; Required Intervention
• Patient Age: 59 YR