MAUDE Adverse Event Report: MEDACTA INTERNATIONAL SA BIPOLAR HEAD Ø28X49; HIP BIPOLAR HEAD

Model Number	25060.2849
Health Effect - Clinical Code	Unspecified Infection (1930)
Date of Event	02/20/2022
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Batch review performed on 23 feb 2022: lot 180449: 34 items manufactured and released on 13-jun-2018.Expiration date: 2023-may-28.No anomalies found related to the problem.To date, 25 items of the same lot have been sold with no similar reported event.Additional device involved: batch review performed on 23 feb 2022: ball heads: mectacer 01.29.202 biolox delta ceramic ball head 12/14 ø 28 size m 0 (k112115) lot 2111102: 200 items manufactured and released on 24-noc-2021.Expiration date: 2026-nov-11 no anomalies found related to the problem.To date, 109 items of the same lot have been sold with no similar reported event.
Event or Problem Description
The patient came in due to signs of an infection and the pathogen is unknown.About 2 weeks after the primary surgery, the surgeon performed a washout and revised the head and the surgery was completed successfully.

• Brand Name: BIPOLAR HEAD Ø28X49
• Common Device Name: HIP BIPOLAR HEAD
• 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: 13802614
• Report Number: 3005180920-2022-00191
• Device Sequence Number: 5032914
• Product Code: KWY
• UDI-Device Identifier: 07630030843693
• UDI-Public: 07630030843693
• Combination Product (Y/N): N
• Initial Reporter State: IL
• Initial Reporter Country: US
• PMA/510(K) Number: K091967
• 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): 03/17/2022

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: 05/28/2023
• Device Model Number: 25060.2849
• Device Catalogue Number: 25060.2849
• Device Lot Number: 180449
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 02/20/2022
• Initial Report FDA Received Date: 03/17/2022
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 06/13/2018
• 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