MAUDE Adverse Event Report: MICROPORT ORTHOPEDICS INC. DYNASTY® A-CLASS® STD POLY LINER 28MM GROUP B; HIP COMPONENT

Model Number	DLXPGB28
Medical Device Problem Codes	Detachment of Device or Device Component (2907); Noise, Audible (3273)
Health Effect - Clinical Codes	Pain (1994); Metal Related Pathology (4530)
Type of Reportable Event	Serious Injury
Event or Problem Description
Allegedly, the patient presented to hospital complaining right hip pain and squeaking.X ray taken indicated worn of prosthetic ball and socket.Surgeon found darkened tissue consistent with metallosis.Further inspection revealed what appeared to be a complete dissociation of the acetabular liner from the underlying acetabulum.Surgeon also noted: significant wear of the locking mechanism at the 10 o´clock position of the polyethylene was shredded off the edge of the polyethylene.The femoral head, the shell and liner were each removed.The acetabular component and liner were replaced with devices not manufactured by wright medical.
Additional Manufacturer Narrative
This event will be updated once the investigation is complete.Trends will be evaluated.

• Brand Name: DYNASTY® A-CLASS® STD POLY LINER 28MM GROUP B
• 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: 12901435
• Report Number: 3010536692-2021-00569
• Device Sequence Number: 3947834
• Product Code: JDI
• UDI-Device Identifier: M684DLXPGB281
• UDI-Public: M684DLXPGB281
• Combination Product (Y/N): N
• Initial Reporter State: FL
• Initial Reporter Country: US
• PMA/510(K) Number: K140043
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2014
• Device Explanted Year: 2020
• 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,Followup
• Report Date (Section B): 10/20/2023

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: DLXPGB28
• Device Catalogue Number: DLXPGB28
• Device Lot Number: 1527166
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 11/01/2021
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 11/01/2021
• Supplement Date Received by Manufacturer: 11/01/2021; 11/01/2021
• Initial Report FDA Received Date: 11/30/2021
• Supplement Report FDA Received Date: 01/24/2022; 10/20/2023
• 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
• Patient Sex: Unknown