MAUDE Adverse Event Report: MEDACTA INTERNATIONAL SA STEM: QUADRA-P COLLARED QUADRA-P COLLARED STD STEM SIZE 1; CEMENTLESS STEM

Model Number	01.12.161
Medical Device Problem Code	Device Appears to Trigger Rejection (1524)
Health Effect - Clinical Code	Unspecified Infection (1930)
Date of Event	10/11/2022
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Batch review performed on 17 october 2022: lot 2114286: (b)(4) manufactured and released on 09-feb-2022.Expiration date: 2027-01-19.No anomalies found related to the problem.To date, (b)(4) of the same lot have been sold with another similar reported event in the period of review.Additional item involved in the event, batch review performed on 17 october 2022: ball heads: mectacer 01.29.202 biolox delta ceramic ball head 12/14 ø 28 size m 0 (k112115) lot.2200854.Lot 2200854: (b)(4) manufactured and released on 10-may-2022.Expiration date: 2027-04-24.No anomalies found related to the problem.To date, (b)(4) of the same lot have been sold without any similar reported event in the period of review.
Event or Problem Description
The patient came in due to signs of an infection and the pathogen is unknown.At about 1 month from the primary surgery the surgeon performed a washout and revised the stem and head.The surgery was completed successfully.

• Brand Name: STEM: QUADRA-P COLLARED QUADRA-P COLLARED STD STEM SIZE 1
• Common Device Name: CEMENTLESS STEM
• Manufacturer (Section D): MEDACTA INTERNATIONAL SA; strada regina; castel san pietro, switzerland 6874 ; SZ 6874
• Manufacturer (Section G): MEDACTA INTERNATIONAL SA; strada regina; castel san pietro, switzerland 6874 ; SZ 6874
• Manufacturer Contact: stefano baj ; strada regina; castel san pietro, switzerland 6874 ; SZ 6874
• MDR Report Key: 15680512
• Report Number: 3005180920-2022-00823
• Device Sequence Number: 17753232
• Product Code: LZO
• UDI-Device Identifier: 07630040731850
• UDI-Public: 07630040731850
• Combination Product (Y/N): N
• Initial Reporter State: IL
• Initial Reporter Country: US
• PMA/510(K) Number: K192827
• 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): 10/27/2022

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: 01.12.161
• Device Catalogue Number: 01.12.161
• Device Lot Number: 2114286
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 10/11/2022
• Initial Report FDA Received Date: 10/27/2022
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 02/09/2022
• 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: Unknown