MAUDE Adverse Event Report: SMITH & NEPHEW ORTHOPAEDICS AG POLARSTEM STEM STD TI/HA 0 NON-CEM; PROSTHESIS, HIP, SEMI-CONSTRAINED, METAL/CERAMIC/POLYMER, CEMENTED OR NON-POROUS

Model Number	75100463
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Bone Fracture(s) (1870)
Date of Event	09/28/2021
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Internal complaint reference (b)(4).
Event or Problem Description
It was reported that, after a thr surgery, the patient fall and experienced a femur fracture.This adverse event led to a revision surgery performed on (b)(6) 2021 in which a polarstem stem std ti/ha 0 non-cem and a cocr 12/14 fem head 32 + 4 were explanted and accord trochanteric grip plate was implanted with cables.The current health status of the patient is unknown.
Additional Manufacturer Narrative
H3, h6: it was reported that, after a total hip replacement surgery, the patient fell and experienced a femur fracture.This adverse event led to a revision surgery performed on (b)(6) 2021 in which a polarstem stem std ti/ha 0 non-cem was explanted.The device, used in treatment was not returned for evaluation, therefore further analysis was not possible.Therefore, the relationship between the reported event and the device cannot be confirmed.However, based on the communicated information, the product history could be reviewed.The production documentation was reviewed.There are no indications that the part failed to match specification at the time of manufacturing.There were no further complaints reported for the batch in scope.The failure mode and the severity are covered through the corresponding risk management files.The ifu lit.No.12.23, ed.03/21 lists hip fracture as potential adverse device effect.A thorough medical assessment was not possible due to missing information.However, it cannot be excluded that the reported fall of the patient led to the reported event.To conclude, the root cause stays undetermined after investigation.The reported fall of the patient could have contributed to the reported issue.To date, further actions are not deemed necessary.Should additional information become available, this complaint will be reassessed.Smith and nephew will monitor this device for further similar issues.

• Brand Name: POLARSTEM STEM STD TI/HA 0 NON-CEM
• Common Device Name: PROSTHESIS, HIP, SEMI-CONSTRAINED, METAL/CERAMIC/POLYMER, CEMENTED OR NON-POROUS
• Manufacturer (Section D): SMITH & NEPHEW ORTHOPAEDICS AG; schachenallee 29; aarau CH-50 00; SZ CH-5000
• Manufacturer (Section G): SMITH & NEPHEW ORTHOPAEDICS AG; schachenallee 29; aarau CH-50 00; SZ CH-5000
• Manufacturer Contact: holly topping ; 7000 west william cannon drive; austin, TX 78735 ; 5123913905
• MDR Report Key: 12615263
• Report Number: 9613369-2021-00386
• Device Sequence Number: 3473194
• Product Code: LZO
• UDI-Device Identifier: 07611996118544
• UDI-Public: 07611996118544
• Combination Product (Y/N): N
• Initial Reporter Country: AS
• PMA/510(K) Number: K130728
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Explanted Year: 2021
• Reporter Type: Manufacturer
• Report Source: Foreign,Health Professional,User Facility
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 11/23/2021

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: 04/30/2026
• Device Model Number: 75100463
• Device Catalogue Number: 75100463
• Device Lot Number: B1909194
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 09/28/2021
• Supplement Date Received by Manufacturer: 11/22/2021
• Initial Report FDA Received Date: 10/12/2021
• Supplement Report FDA Received Date: 11/23/2021
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 05/02/2019
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Hospitalization; Other
• Patient Sex: Unknown