MAUDE Adverse Event Report: MICROPORT ORTHOPEDICS INC. PROFEMUR® R GRIT BLASTED PROX BODY SMALL; HIP COMPONENT

Model Number	PPW39102
Health Effect - Clinical Code	Unspecified Infection (1930)
Date of Event	01/28/2022
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, patient was ex domo (prof r implantation in another hospital).Prosthesis pseudo- arthritic, broken stem below proximal part.Regarding a low grade infect as differential diagnosis, stem and cup explanted in (b)(6) hospital.Bfarm case number: (b)(4).

• Brand Name: PROFEMUR® R GRIT BLASTED PROX BODY SMALL
• 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: 13639845
• Report Number: 3010536692-2022-00059
• Device Sequence Number: 19363997
• Product Code: LWJ
• UDI-Device Identifier: M684PPW391021
• UDI-Public: M684PPW391021
• Combination Product (Y/N): N
• Initial Reporter Country: GM
• PMA/510(K) Number: K003016
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Explanted Year: 2022
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Other,Foreign
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 05/05/2022

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: PPW39102
• Device Catalogue Number: PPW39102
• Device Lot Number: 1563308
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 02/11/2022
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 02/11/2022
• Supplement Date Received by Manufacturer: 02/11/2022
• Initial Report FDA Received Date: 03/01/2022
• Supplement Report FDA Received Date: 05/06/2022
• 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 Age: 75 YR
• Patient Sex: Unknown
• Patient Weight: 85 KG