MAUDE Adverse Event Report: MEDACTA INTERNATIONAL SA BALL HEADS: MECTACER HEAD BIOLOX OPTION Ø 40; HIP CERAMIC HEAD

Model Number	01.29.233H
Medical Device Problem Code	Device Appears to Trigger Rejection (1524)
Health Effect - Clinical Code	Unspecified Infection (1930)
Date of Event	03/08/2023
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Batch review performed on 06-apr-2023.Lot 2115395: (b)(4) items manufactured and released on 02-feb-2022.Expiration date: 2027-01-24.No anomalies found related to the problem.To date, (b)(4) items of the same lot have been sold with no similar reported case during the period of review.Additional devices involved: ball heads: mectacer 01.29.242a sleeve size l (k131518) lot 22c0012: (b)(4) items manufactured and released on 08-mar-2022.Expiration date: 2027-02-15.No anomalies found related to the problem.To date, (b)(4) items of the same lot have been sold with no similar reported case during the period of review.Liner: mpact 01.32.4052hc10a face-changing 10° pe hc liner ø40/g (k183582) lot 1810856: (b)(4) items manufactured and released on 04-apr-2019.Expiration date: 2024-03-19.No anomalies found related to the problem.To date, (b)(4) items of the same lot have been sold with another similar reported case during the period of review.Cup: mpact 01.32.162dh acetabular shell ø62 two-holes (k132879) lot 178265: (b)(4) items manufactured and released on 20-mar-2018.Expiration date: 2023-03-09.No anomalies found related to the problem.To date, (b)(4) items of the same lot have been sold with no similar reported case during the period of review.Stem: amistem-p collared 01.18.438 amistem-p collared std stem size 8 (k173794) lot 1900091: (b)(4) items manufactured and released on 02-may-2019.Expiration date: 2024-04-16.No anomalies found related to the problem.To date, (b)(4) items of the same lot have been sold with no similar reported case during the period of review.
Event or Problem Description
The patient had a primary hip surgery on (b)(6) 2019.On (b)(6) 2022, the patient came in reporting pain due to a dislocation of the head from the liner and the cause is unknown.The surgeon revised successfully the head and liner.On (b)(6) 2022, the patient came in due to signs of an infection and the pathogen was unknown.The surgeon performed a washout and revised successfully the head and liner.Presently, on (b)(6) 2023 the patient came in due to signs of an infection and the pathogen is unknown.The surgeon performed a washout and removed all components and implanted permanent hardware.The surgery was completed successfully.

• Brand Name: BALL HEADS: MECTACER HEAD BIOLOX OPTION Ø 40
• Common Device Name: HIP CERAMIC 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: marco giannessi ; strada regina; castel san pietro, switzerland 6874 ; SZ 6874
• MDR Report Key: 16689565
• Report Number: 3005180920-2023-00238
• Device Sequence Number: 7346862
• Product Code: LZO
• UDI-Device Identifier: 07630030809354
• UDI-Public: 07630030809354
• Combination Product (Y/N): N
• Initial Reporter State: IL
• Initial Reporter Country: US
• PMA/510(K) Number: K131518
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2022
• Device Explanted Year: 2023
• 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): 04/06/2023

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: 01.29.233H
• Device Catalogue Number: 01.29.233H
• Device Lot Number: 2115395
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 03/08/2023
• Initial Report FDA Received Date: 04/06/2023
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 02/02/2022
• 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