MAUDE Adverse Event Report: MICROPORT ORTHOPEDICS INC. SLR BIPOLAR INSERT 41-44MM X 28MM ID; HIP COMPONENT

Model Number	17002802
Medical Device Problem Code	Device Dislodged or Dislocated (2923)
Health Effect - Clinical Code	Insufficient Information (4580)
Date of Event	07/20/2023
Type of Reportable Event	Serious Injury
Event or Problem Description
Allegedly, patient came in for routine post-op examination on (b)(6) 2023.X-rays were taken and it was found that the patient's glenosphere had completely dislocated from the liner.No discomfort or loss of utility was reported and no incident was identified which could have caused the dislocation.The liner was replaced with a new slr liner on (b)(6) 2023.(b)(4).
Additional Manufacturer Narrative
This event will be updated once the investigation is complete.Trends will be evaluated.

• Brand Name: SLR BIPOLAR INSERT 41-44MM X 28MM ID
• Common Device Name: HIP COMPONENT
• Manufacturer (Section D): MICROPORT ORTHOPEDICS INC.; 5677 airline rd.; arlington TN 38002
• Manufacturer Contact: rachael wise ; 5677 airline road; arlington, TN 38002 ; 9018674771
• MDR Report Key: 17676585
• Report Number: 3010536692-2023-00158
• Device Sequence Number: 20447305
• Product Code: KWY
• UDI-Device Identifier: M684170028021
• UDI-Public: M684170028021
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K861566
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2023
• Device Explanted Year: 2023
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Other
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 11/10/2023

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: Other
• Device Model Number: 17002802
• Device Catalogue Number: 17002802
• Device Lot Number: 1908771
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 08/07/2023
• Supplement Date Received by Manufacturer: 08/07/2023
• Initial Report FDA Received Date: 09/04/2023
• Supplement Report FDA Received Date: 11/10/2023
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Is the Device Labeled for Single Use? (Y/N): Yes
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 45 YR
• Patient Sex: Male