MAUDE Adverse Event Report: MICROPORT ORTHOPEDICS INC. PROFEMUR® TL CLASSIC STEM SIZE 8 VARUS 8 DG SHORT; HIP COMPONENT

Model Number	PRTLE028
Medical Device Problem Code	Insufficient Device Problem Information (3190)
Health Effect - Clinical Code	Bone Fracture(s) (1870)
Type of Reportable Event	Serious Injury
Event or Problem Description
Allegedly, patient was revised due to periprosthetic fracture.Srnjr number: 5374756 side: l.Gender: f.

• Brand Name: PROFEMUR® TL CLASSIC STEM SIZE 8 VARUS 8 DG SHORT
• 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: 19013373
• Report Number: 3010536692-2024-00153
• Device Sequence Number: 8172273
• Product Code: JDI
• UDI-Device Identifier: M684PRTLE0281
• UDI-Public: M684PRTLE0281
• Combination Product (Y/N): N
• Initial Reporter Country: UK
• PMA/510(K) Number: K123688
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2018
• Device Explanted Year: 2023
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 04/01/2024

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 Model Number: PRTLE028
• Device Catalogue Number: PRTLE028
• Device Lot Number: 1671590
• 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: 03/05/2024
• Initial Report FDA Received Date: 04/01/2024
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Is the Device Labeled for Single Use? (Y/N): Yes
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 82 YR
• Patient Sex: Female