MAUDE Adverse Event Report: MEDACTA INTERNATIONAL SA BALL HEADS: COCR BALL HEAD 12/14 Ø 28 SIZE L +3.5; HIP ACETABULAR METAL HEAD

Model Number	01.25.013
Medical Device Problem Code	Device Appears to Trigger Rejection (1524)
Health Effect - Clinical Code	Medical device site infection (4845)
Date of Event	12/24/2022
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Batch review performed on 28 december 2022.Lot 2113049: (b)(4) items manufactured and released on 05-jan-2022.Expiration date: 2026-12-13.No anomalies found related to the problem.To date, (b)(4) items of the same lot have been sold without any similar reported event during the period of review.Additional component involved in the event: ball heads: bipolar head 25060.2851 bipolar head ø28x51 lot.2116131: (b)(4) items manufactured and released on 07-march-2022.Expiration date: 2027-02-21.No anomalies found related to the problem.To date, (b)(4) items of the same lot have been sold without any similar reported event during the period of review.
Event or Problem Description
At about 1 week after the primary, the patient came in due to signs of an infection and the pathogen is unknown.The surgeon performed a washout, revised the head and bipolar head and the surgery was completed successfully.

• Brand Name: BALL HEADS: COCR BALL HEAD 12/14 Ø 28 SIZE L +3.5
• Common Device Name: HIP ACETABULAR METAL HEAD
• 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: 16094458
• Report Number: 3005180920-2022-01003
• Device Sequence Number: 6659619
• Product Code: JDI
• UDI-Device Identifier: 07630030805127
• UDI-Public: 07630030805127
• Combination Product (Y/N): N
• Initial Reporter State: IL
• Initial Reporter Country: US
• PMA/510(K) Number: K072857
• 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: Company Representative
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 01/04/2023

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: 01.25.013
• Device Catalogue Number: 01.25.013
• Device Lot Number: 2113049
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 12/24/2022
• Initial Report FDA Received Date: 01/04/2023
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 01/05/2022
• 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: Male