MAUDE Adverse Event Report: MEDACTA INTERNATIONAL SA CUP: MPACT 3D METAL 01.38.054DH ACETABULAR SHELL Ø54 TWO-HOLE; HIP ACETABULAR SHELL

Model Number	01.38.054DH
Health Effect - Clinical Code	Pain (1994)
Date of Event	06/09/2022
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Batch review performed on (b)(6) 2022.Lot 2006765: 31 items manufactured and released on (b)(6) 2020.Expiration date: 2025-09-30.No anomalies found related to the problem.To date, 29 items of the same lot have been sold with no similar reported case during the period of review.
Event or Problem Description
The patient came in reporting pain due to a loose cup and the cause of the loose cup is unknown.At 1 year and 4 months after the primary surgery, the surgeon revised the cup, head and liner.The surgery was completed successfully.

• Brand Name: CUP: MPACT 3D METAL 01.38.054DH ACETABULAR SHELL Ø54 TWO-HOLE
• Common Device Name: HIP ACETABULAR SHELL
• 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: 14955243
• Report Number: 3005180920-2022-00513
• Device Sequence Number: 5395772
• Product Code: LPH
• UDI-Device Identifier: 07630030812606
• UDI-Public: 07630030812606
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K171966
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2021
• Device Explanted Year: 2022
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Other
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 07/08/2022

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: 09/30/2025
• Device Model Number: 01.38.054DH
• Device Catalogue Number: 01.38.054DH
• Device Lot Number: 2006765
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 06/09/2022
• Initial Report FDA Received Date: 07/08/2022
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 10/19/2020
• 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