MAUDE Adverse Event Report: MICROPORT ORTHOPEDICS INC. DYNASTY PC SHELL 58MM GROUP G; HIP COMPONENT

Model Number	DSPCGG58
Medical Device Problem Codes	Material Disintegration (1177); Naturally Worn (2988)
Health Effect - Clinical Code	Loss of Range of Motion (2032)
Date of Event	04/12/2021
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
This event will be updated once the investigation is complete.Trends will be evaluated.
Event or Problem Description
Allegedly, patient was in kitchen and felt a "pop" and then the joint squeaked.X-rays indicated a suspected cracked poly liner.During revision it was seem that the poly was intact but the patient was impinging and wearing the rim of the liner and cup.Cup was revised and a biolox delta option head was implanted.Possibly patient was externally rotating excessively leading to impingement and eccentric wear.Products not revised: profemur plasma z classic femoral stem w/long neck size 7 varus 8 degree / product id: phape244 / lot number: 0798768751605863.

• Brand Name: DYNASTY PC SHELL 58MM GROUP G
• Common Device Name: HIP COMPONENT
• Manufacturer (Section D): MICROPORT ORTHOPEDICS INC.; 5677 airline rd.; arlington TN 38002
• MDR Report Key: 11812446
• Report Number: 3010536692-2021-00287
• Device Sequence Number: 3510111
• Product Code: LZO
• UDI-Device Identifier: M684DSPCGG581
• UDI-Public: M684DSPCGG581
• 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: 2020
• Device Explanted Year: 2021
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 07/09/2021

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: DSPCGG58
• Device Catalogue Number: DSPCGG58
• Device Lot Number: 1822162
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 04/20/2021
• Initial Date Received by Manufacturer: 04/20/2021
• Supplement Date Received by Manufacturer: 04/20/2021
• Initial Report FDA Received Date: 05/12/2021
• Supplement Report FDA Received Date: 07/09/2021
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 52 YR
• Patient Weight: 166