MAUDE Adverse Event Report: MEDACTA INTERNATIONAL SA STEM: QUADRA-P LAT STEM SIZE 4

Model Number	01.12.144
Medical Device Problem Code	Malposition of Device (2616)
Health Effect - Clinical Code	Pain (1994)
Date of Event	09/30/2021
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Batch review performed on 1 october 2021: lot 2009100: (b)(4) items manufactured and released on 11-jan-2021.Expiration date: 2025-dec-21.No anomalies found related to the problem.To date, (b)(4) items of the same lot have been sold without any similar reported event.
Event or Problem Description
The patient came in reporting pain due to the stem being too anteverted after the primary hip surgery.The surgeon implanted the stem anteverted in primary.At 3 days after the primary surgery, the surgeon revised the stem, sleeve, and head.The surgery was completed successfully.

• Brand Name: STEM: QUADRA-P LAT STEM SIZE 4
• Common Device Name: QUADRA-P
• Manufacturer (Section D): MEDACTA INTERNATIONAL SA; strada regina; castel san pietro, 6874 ; SZ 6874
• MDR Report Key: 12712182
• Report Number: 3005180920-2021-00837
• Device Sequence Number: 4985406
• Product Code: LZO
• UDI-Device Identifier: 07630040720564
• UDI-Public: 07630040720564
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K181254
• 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
• 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?: Yes
• Is this a Product Problem Report?: No
• Operator of Device: Health Professional
• Device Expiration Date: 12/21/2025
• Device Model Number: 01.12.144
• Device Catalogue Number: 01.12.144
• Device Lot Number: 2009100
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 09/30/2021
• Initial Report FDA Received Date: 10/28/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention