MAUDE Adverse Event Report: GLOBUS MEDICAL, INC. STELKAST HIP ARTHROPLASTY; PROVIDENT HIP STEM, LATERAL, 10MM

Model Number	SC2658-10.0
Medical Device Problem Code	Use of Device Problem (1670)
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	12/19/2022
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that a revision was needed to replace a stelkast hip implant that failed post operatively.
Additional Manufacturer Narrative
This report is being resubmitted for an incident that occurred earlier.The device could not be provided for evaluation.The imaging provided shows the femoral head center of rotation appears to shift laterally.No determinations could be made as to the cause of the reported issue.

• Brand Name: STELKAST HIP ARTHROPLASTY
• Common Device Name: PROVIDENT HIP STEM, LATERAL, 10MM
• Manufacturer (Section D): GLOBUS MEDICAL, INC.; 2560 general armistead avenue; audubon PA 19403
• Manufacturer (Section G): GLOBUS MEDICAL, INC.; 2560 general armistead avenue; audubon PA 19403
• Manufacturer Contact: daniel paul ; 2560 general armistead avenue; audubon, PA 19403 ; 6109301800
• MDR Report Key: 18834167
• Report Number: 3004142400-2023-00051
• Device Sequence Number: 17953392
• Product Code: LWJ
• UDI-Device Identifier: 10840843107170
• UDI-Public: 10840843107170
• Combination Product (Y/N): N
• Initial Reporter State: PA
• Initial Reporter Country: US
• PMA/510(K) Number: K002796
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2020
• Device Explanted Year: 2022
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 03/01/2024

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Model Number: SC2658-10.0
• Device Lot Number: 42711
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 03/08/2023
• Initial Report FDA Received Date: 03/05/2024
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 03/06/2018
• 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: Other
• Patient Sex: Unknown