MAUDE Adverse Event Report: MEDACTA INTERNATIONAL SA QUADRA-P SHORT NECK LAT STEM SIZE 2; HIP STEM CEMENTLESS

Model Number	01.12.272
Medical Device Problem Code	Migration (4003)
Health Effect - Clinical Code	Pain (1994)
Date of Event	12/20/2021
Type of Reportable Event	Serious Injury
Event or Problem Description
The patient came in 1 month after the primary reporting pain due to a subsided stem and the cause of the subsided stem is unknown.The surgeon revised the stem, head and liner.
Additional Manufacturer Narrative
Batch review performed on 23 december 2021.Lot 1910222: (b)(4) items manufactured and released on 16-apr-2020.Expiration date: 2025-apr-06.No anomalies were found related to the problem.To date, (b)(4) items of the same lot have been sold without similar reported events.

• Brand Name: QUADRA-P SHORT NECK LAT STEM SIZE 2
• Common Device Name: HIP STEM CEMENTLESS
• Manufacturer (Section D): MEDACTA INTERNATIONAL SA; strada regina; castel san pietro, 6874 ; SZ 6874
• Manufacturer (Section G): MEDACTA INTERNATIONAL SA; strada regina; castel san pietro, 6874 ; SZ 6874
• Manufacturer Contact: stefano baj ; strada regina; castel san pietro, switzerland 6874 ; SZ 6874
• MDR Report Key: 13280937
• Report Number: 3005180920-2022-00021
• Device Sequence Number: 4873310
• Product Code: LZO
• UDI-Device Identifier: 07630971243545
• UDI-Public: 07630971243545
• Combination Product (Y/N): N
• Initial Reporter State: IL
• Initial Reporter Country: US
• PMA/510(K) Number: K192827
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2021
• Device Explanted Year: 2021
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Other
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 01/18/2022

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: Health Professional
• Device Expiration Date: 04/06/2025
• Device Model Number: 01.12.272
• Device Catalogue Number: 01.12.272
• Device Lot Number: 1910222
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 12/20/2021
• Initial Report FDA Received Date: 01/18/2022
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 04/16/2020
• 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: Required Intervention
• Patient Sex: Female