MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS INC US BI MENTUM PFRK PE LINER 22 43; BI MENTUM LINER

Model Number	BI-MENTUM PE Liner 22,2 / 43
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Joint Dislocation (2374)
Date of Event	05/29/2022
Type of Reportable Event	Serious Injury
Event or Problem Description
Patient was revised due to dislocation.The surgeon removed cup, head, and liner and replaced with stryker dual mobility.No surgical delay was reported.Doi: (b)(6) 2022; dor: (b)(6) 2022; affected side: right hip.
Additional Manufacturer Narrative
Product complaint # (b)(4).

• Brand Name: BI MENTUM PFRK PE LINER 22 43
• Common Device Name: BI MENTUM LINER
• Manufacturer (Section D): DEPUY ORTHOPAEDICS INC US; 700 orthopaedic drive; warsaw IN 46581 0988
• MDR Report Key: 14685573
• Report Number: 1818910-2022-50030
• Device Sequence Number: 14657363
• Product Code: LPH
• UDI-Device Identifier: 03662200015504
• UDI-Public: 03662200015504
• Combination Product (Y/N): N
• Initial Reporter State: CA
• 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): 06/14/2022
• Report Date (Section F): 06/14/2022

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 / 43
• Device Catalogue Number: DS10014322
• Device Lot Number: 2002689A
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: Yes
• Distributor Facility Aware Date: 05/29/2022
• Event Location: Hospital
• Date Report to Manufacturer: 06/03/2022
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 06/14/2022
• Date Device Manufactured: 10/17/2020
• 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+4 NK; PINNACLE DM LINER 50_43
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 64 YR
• Patient Sex: Female
• Date Report Sent to FDA: 06/14/2022