MAUDE Adverse Event Report: MEDACTA INTERNATIONAL SA SMS SOLID COLLARED SMS COLLARED SOLID STEM LAT SIZE 9; HIP CEMENTLESS STEM

Catalog Number	01.36.169
Medical Device Problem Code	Osseointegration Problem (3003)
Health Effect - Clinical Code	Inadequate Osseointegration (2646)
Date of Event	12/26/2023
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Batch review performed on 29-dec-2023: lot 2209156: (b)(4) items manufactured and released on 21-sep-2022.Expiration date: 2027-09-06.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.Clinical evaluation performed by medacta medical affairs manager: revision at about 6 months after primary tha, due to a loose stem.Since only 6 months have passed, it seems the stem had never found primary stability.It may be due to the undersized stem or due to other factors which we cannot determine also because no other images of different projections are provided.The reason of this failure cannot be determined.
Event or Problem Description
At about 6 months after primary, the patient came in reporting pain due to a loose stem and the cause is unknown.The surgeon revised successfully the stem and head.

• Brand Name: SMS SOLID COLLARED SMS COLLARED SOLID STEM LAT SIZE 9
• Common Device Name: HIP 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: marco giannessi ; strada regina; castel san pietro, switzerland 6874 ; SZ 6874
• MDR Report Key: 18578385
• Report Number: 3005180920-2023-01112
• Device Sequence Number: 7708741
• Product Code: LZO
• UDI-Device Identifier: 07630345701916
• UDI-Public: 07630345701916
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K203041
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2023
• Device Explanted Year: 2023
• 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): 01/25/2024

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: 01.36.169
• Device Lot Number: 2209156
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 12/26/2023
• Initial Report FDA Received Date: 01/25/2024
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 09/21/2022
• 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 Age: 59 YR
• Patient Sex: Male