MAUDE Adverse Event Report: MEDACTA INTERNATIONAL SA LINER: MPACT FLAT PE HC LINER Ø28/B; HIP SHELL LINER

Model Number	01.32.2837HCT
Health Effect - Clinical Code	Unspecified Infection (1930)
Date of Event	07/18/2022
Type of Reportable Event	Serious Injury
Event or Problem Description
At about 1 month after the primary, the patient came in due to signs of an infection and the pathogen is unknown.The surgeon performed a washout and revised the poly and the surgery was completed successfully.
Additional Manufacturer Narrative
Batch review performed on 02 august 2022: lot 1810214: 44 items manufactured and released on 10-dec-2018.Expiration date: 2023-11-27.No anomalies found related to the problem.To date, 35 items of the same lot have been sold without any similar reported event during the period of review.Additional device involved batch review performed on 02 august 2022 screws: mpact 01.43.0025 cancellous bone screw ø 6,5 l 25 (k200391) lot 2208670: 314 items manufactured and released on 08-june-2022.Expiration date: 2027-05-23.No anomalies found related to the problem.To date, 70 items of the same lot have been sold without any similar reported event during the period of review.

• Brand Name: LINER: MPACT FLAT PE HC LINER Ø28/B
• Common Device Name: HIP SHELL LINER
• 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: 15154907
• Report Number: 3005180920-2022-00609
• Device Sequence Number: 5323812
• Product Code: LPH
• UDI-Device Identifier: 07630030811531
• UDI-Public: 07630030811531
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K103721
• 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: Other
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 08/03/2022

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: 11/27/2023
• Device Model Number: 01.32.2837HCT
• Device Catalogue Number: 01.32.2837HCT
• Device Lot Number: 1810214
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 07/18/2022
• Initial Report FDA Received Date: 08/03/2022
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 12/10/2018
• 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: Female