MAUDE Adverse Event Report: SERF BI MENTUM PFRK PE LINER 22 41; BI MENTUM LINER

Model Number	BI-MENTUM PE Liner 22,2 / 41
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Unspecified Infection (1930)
Date of Event	05/24/2022
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Product complaint # (b)(4).
Event or Problem Description
Patient was revised due to infection.Doi: (b)(6) 2022, dor: (b)(6) 2022, affected side: right hip.

• Brand Name: BI MENTUM PFRK PE LINER 22 41
• Common Device Name: BI MENTUM LINER
• Manufacturer (Section D): SERF; 85 avenue des bruyères; décines-charpieu 69150 ; FR 69150
• MDR Report Key: 14653560
• Report Number: 1818910-2022-50028
• Device Sequence Number: 4764635
• Product Code: LPH
• UDI-Device Identifier: 03662200015498
• UDI-Public: 03662200015498
• Combination Product (Y/N): N
• Initial Reporter State: NC
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2022
• Device Explanted Year: 2022
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Importer
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 06/10/2022
• Report Date (Section F): 06/10/2022

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 Model Number: BI-MENTUM PE Liner 22,2 / 41
• Device Catalogue Number: DS10014122
• Device Lot Number: 2009382A
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: Yes
• Distributor Facility Aware Date: 05/24/2022
• Event Location: Hospital
• Date Report to Manufacturer: 05/26/2022
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 06/10/2022
• Date Device Manufactured: 01/08/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: ARTICUL/EZE BALL 22.225+7 NK; BI MENTUM PFRK PE LINER 22 41
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 77 YR
• Patient Sex: Female
• Patient Weight: 68 KG
• Date Report Sent to FDA: 06/10/2022