MAUDE Adverse Event Report: MICROPORT ORTHOPEDICS INC. PROFEMUR R GRIT BLASTED PROX BODY STD 1 V4; HIP COMPONENT

Model Number	PPW39104
Health Effect - Clinical Code	Bone Fracture(s) (1870)
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, a patient was revised for greater trochanter fracture.Components not revised: product name: profemur(r) proximal body part id: ppw39104.Product name: profemur(r) roughened distal stem, tapered part id: ppw38005.Product name: unknown cup, unknown part id and lot number.

• Brand Name: PROFEMUR R GRIT BLASTED PROX BODY STD 1 V4
• Common Device Name: HIP COMPONENT
• Manufacturer (Section D): MICROPORT ORTHOPEDICS INC.; 5677 airline rd.; arlington TN 38002
• MDR Report Key: 12430950
• Report Number: 3010536692-2021-00500
• Device Sequence Number: 5361000
• Product Code: LWJ
• UDI-Device Identifier: M684PPW391041
• UDI-Public: M684PPW391041
• Combination Product (Y/N): N
• Initial Reporter Country: IT
• PMA/510(K) Number: K003016
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2012
• Device Explanted Year: 2012
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 10/28/2021

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: Other
• Device Model Number: PPW39104
• Device Catalogue Number: PPW39104
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 08/12/2021
• Initial Date Received by Manufacturer: 08/12/2021
• Supplement Date Received by Manufacturer: 08/12/2021
• Initial Report FDA Received Date: 09/06/2021
• Supplement Report FDA Received Date: 10/28/2021
• Patient Sequence Number: 1