MAUDE Adverse Event Report: MEDACTA INTERNATIONAL SA STEM: SMS SOLID SMS COLLARED SOLID STEM LAT SIZE 8; CEMENTLESS HIP STEM

Model Number	01.36.168
Health Effect - Clinical Code	Hip Fracture (2349)
Date of Event	02/09/2022
Type of Reportable Event	Serious Injury
Event or Problem Description
At 14 days after the primary, the patient came in reporting pain due to a periprosthetic fracture and the cause is unknown.The surgeon cabled the fracture and revised the stem and head.The surgery was completed successfully.
Additional Manufacturer Narrative
Batch review performed on 10 february 2022.Lot 2102623: (b)(4) items manufactured and released on 05-july-2021.Expiration date: 2026-06-21.No anomalies found related to the problem.To date, (b)(4) items of the same lot have been sold without any similar reported event.Clinical evaluation performed by clinical affairs specialist.Few days after primary cementless tha a periprosthetic fracture occurs with no trauma reported.It is conceivable that during surgery, in particular during femoral preparation, the bone may have been weakened and a least-resistance area may have been created.This is a known possible adverse event following tha and there is no reason to suspect that it is due to a defect in the implanted device or in the preparing instruments.

• Brand Name: STEM: SMS SOLID SMS COLLARED SOLID STEM LAT SIZE 8
• Common Device Name: CEMENTLESS HIP STEM
• 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: 13731920
• Report Number: 3005180920-2022-00164
• Device Sequence Number: 11918177
• Product Code: LZO
• UDI-Device Identifier: 07630345701909
• UDI-Public: 07630345701909
• Combination Product (Y/N): N
• Initial Reporter State: IL
• Initial Reporter Country: US
• PMA/510(K) Number: K203041
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2022
• Device Explanted Year: 2022
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 03/11/2022

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: 06/21/2026
• Device Model Number: 01.36.168
• Device Catalogue Number: 01.36.168
• Device Lot Number: 2102623
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 02/09/2022
• Initial Report FDA Received Date: 03/11/2022
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 07/05/2021
• 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: Male