MAUDE Adverse Event Report: MEDACTA INTERNATIONAL SA AMISTEM C FEMORAL STEMS; AMISTEM-C LAT. SIZE 2

Model Number	01.18.102
Medical Device Problem Code	Device Appears to Trigger Rejection (1524)
Health Effect - Clinical Code	Medical device site infection (4845)
Date of Event	11/12/2024
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Batch review performed on 20 november 2024: (b)(4) items manufactured and released on 27-jun-2023.Expiration date: 2028-06-10.No anomalies found related to the problem.To date, (b)(4) items of the same lot have been sold with no similar reported event during the period of review.Additional implants involved: cup: mpact 01.32.158dh acetabular shell ø58 two-holes (k132879) lot.2309120; batch review performed on 20 november 2024.(b)(4) items manufactured and released on 24-aug-2023.Expiration date: 2028-07-29.No anomalies found related to the problem.To date, (b)(4) items of the same lot have been sold with no similar reported event during the period of review.Liner: mpact 01.32.4052hct flat pe hc liner ø40/f (k103721) lot.2213335; batch review performed on 20 november 2024.(b)(4) items manufactured and released on 21-jul-2022.Expiration date: 2027-07-04.No anomalies found related to the problem.To date, (b)(4) items of the same lot have been sold with no similar reported event during the period of review.Ball heads: mectacer 01.29.213 40mm biolox delta head m (k112115) lot.2335716; batch review performed on 20 november 2024.(b)(4) items manufactured and released on 21-sep-2023.Expiration date: 2028-09-02.No anomalies found related to the problem.To date, (b)(4) items of the same lot have been sold with no similar reported event during the period of review.Root cause: infection is a known possible complication of any surgery.Although no root cause can be established, there is no indication that any issue with the device may have caused or contributed to the event, and the document review does not indicate any potential manufacturing related cause.
Event or Problem Description
Revision due to signs of infection and the pathogen is unknown.The primary surgery was on (b)(6) 2023 and the liner head and stem that were substituted on (b)(6) 2024 due to signs of an infection.On (b)(6) 2024, at about 11 months from the precedent revision surgery for infection the surgeon revised all medacta hardware and reimplanted permanent product.The surgery was completed successfully.

• Brand Name: AMISTEM C FEMORAL STEMS
• Common Device Name: AMISTEM-C LAT. SIZE 2
• 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: 20817092
• Report Number: 3005180920-2024-01018
• Device Sequence Number: 8716864
• Product Code: LZO
• UDI-Device Identifier: 07630030803802
• UDI-Public: 07630030803802
• Combination Product (Y/N): N
• Initial Reporter State: MO
• Initial Reporter Country: US
• PMA/510(K) Number: K103189
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2023
• Device Explanted Year: 2024
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 12/02/2024

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: 01.18.102
• Device Lot Number: 2310292
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 11/12/2024
• Initial Report FDA Received Date: 12/02/2024
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 06/27/2023
• 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 Sex: Male