MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS INC US PIN LNR CONS NEUT +4 36IDX58OD; PINNACLE HIP SYSTEM : HIP CONSTRAINED ACETABULAR LINERS

Catalog Number	121836658
Medical Device Problem Code	Noise, Audible (3273)
Health Effect - Clinical Codes	Inflammation (1932); Pain (1994); Ambulation or Postural Difficulties (2544); Unspecified Musculoskeletal problem (4535); Swelling/ Edema (4577)
Type of Reportable Event	Serious Injury
Event or Problem Description
On (b)(6) 2017 states the patient is having right hip pain with popping and grinding (crepitus) when exercising.Patient was diagnosed with right greater trochanter bursitis and was given a cortisone injection.On (b)(6) 2017, he continues to have mild pain with palpation over the right greater trochanter but only recommended intervention is stretching and ice.On (b)(6) 2018, he continues to have mild pain over the right greater trochanter after extended walking and will continue stretches and ice.On (b)(6) 2021, the patient states he has pain and swelling in his right hip and is treating with ice and tylenol.On (b)(6) 2022, an ultrasound shows a large fluid collection in the area of the trochanteric bursa.Aspiration and possible physical therapy is considered though no notes indicate the aspiration occurred.On (b)(6) 2022, patient undergoes a serious of physical therapy treatments for the ongoing swelling and pain over the right hip.Doi: (b)(6) 2013; dor: unrevised; right hip.
Additional Manufacturer Narrative
Product complaint # (b)(4).H6 component code: appropriate term/code not available (g07002) used to capture no findings available.Investigation summary: no device associated with this report was received for examination.The information received will be retained for potential series investigations if triggered by trend analysis, post market surveillance, or other events within the quality system.Depuy considers the investigation closed.Should additional information be received, the information will be reviewed and the investigation will be re-opened as necessary.This report is being submitted pursuant to the provisions of 21 cfr, part 803 (and/or part 4, as applicable).This report may be based on information which has not been investigated or verified prior to the required reporting date.This report does not reflect a conclusion by depuy synthes, or its employees that the report constitutes an admission that the product, depuy synthes, or its employees caused or contributed to the potential event described in this report.If information is obtained that was not available for the initial report, a follow-up report will be filed as appropriate.

• Brand Name: PIN LNR CONS NEUT +4 36IDX58OD
• Common Device Name: PINNACLE HIP SYSTEM : HIP CONSTRAINED ACETABULAR LINERS
• Manufacturer (Section D): DEPUY ORTHOPAEDICS INC US; 700 orthopaedic drive; warsaw IN 46581 0988
• Manufacturer (Section G): JTE WARSAW MFG SITE; 700 orthopaedic drive; warsaw IN
• Manufacturer Contact: kate karberg ; 700 orthopaedic dr.; warsaw, IN 46581-0988 ; 3035526892
• MDR Report Key: 17602608
• Report Number: 1818910-2023-17251
• Device Sequence Number: 6284167
• Product Code: KWZ
• UDI-Device Identifier: 10603295012139
• UDI-Public: 10603295012139
• Combination Product (Y/N): N
• Initial Reporter State: VA
• Initial Reporter Country: US
• PMA/510(K) Number: K043058
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2013
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Other
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 08/23/2023

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 Catalogue Number: 121836658
• Device Lot Number: 114275
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 08/01/2023
• Initial Report FDA Received Date: 08/23/2023
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 06/17/2011
• 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
• Concomitant Medical Products and Therapy/Usage Dates: AML LG STATURE 13.5MM; DLT TS CER HD 12/14 36MM +5.0; PINNACLE 100 ACET CUP 58MM
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Sex: Male
• Patient Ethnicity: Non Hispanic
• Patient Race: White