MAUDE Adverse Event Report: MICROPORT ORTHOPEDICS INC. PROFEMUR® PROXIMAL BODY PLASMA SPRAY; HIP COMPONENT

Model Number	PPW38024
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	Insufficient Information (4580)
Date of Event	09/07/2021
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, the patient had previously been operated on twice, in 2013 and 2014.This time he suffered a stem break, having to undergo surgery again for its removal.
Additional Manufacturer Narrative
Update of the description and section: d.4 change the product and lot.
Event or Problem Description
Allegedly, the patient had previously been operated on twice, in 2013 and 2014.This time he suffered a stem break, having to undergo surgery again for its removal.Additional information received on 03/01/2022 including new products that were revised.

• Brand Name: PROFEMUR® PROXIMAL BODY PLASMA SPRAY
• Common Device Name: HIP COMPONENT
• Manufacturer (Section D): MICROPORT ORTHOPEDICS INC.; 5677 airline rd.; arlington TN 38002
• Manufacturer (Section G): MICROPORT ORTHOPEDICS INC.; 5677 airline rd.; arlington TN 38002
• Manufacturer Contact: 5677 airline road; arlington, TN 38002 ; 9018674771
• MDR Report Key: 12591208
• Report Number: 3010536692-2021-00534
• Device Sequence Number: 4344696
• Product Code: LZO
• UDI-Device Identifier: M684PPW380241
• UDI-Public: M684PPW380241
• Combination Product (Y/N): N
• Initial Reporter Country: AR
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2013
• Device Explanted Year: 2021
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Distributor
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 04/05/2022

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: PPW38024
• Device Catalogue Number: PPW38024
• Device Lot Number: 1478543
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 09/16/2021
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 09/16/2021
• Supplement Date Received by Manufacturer: 09/16/2021
• Initial Report FDA Received Date: 10/07/2021
• Supplement Report FDA Received Date: 04/05/2022
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Is the Device Labeled for Single Use? (Y/N): Yes
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Sex: Male