MAUDE Adverse Event Report: MEDACTA INTERNATIONAL SA COCR FEMORAL BALL HEAD; BALL HEADS: COCR 01.25.033 COCR BALL HEAD 12/14 Ø 36 SIZE XL +7

Model Number	01.25.033
Medical Device Problem Code	Device Dislodged or Dislocated (2923)
Health Effect - Clinical Code	Implant Pain (4561)
Date of Event	12/17/2024
Type of Reportable Event	Serious Injury
Event or Problem Description
The patient had a primary hip surgery with a competitor on an unknown date.Subsequently, the patient came in for an unknown reason and the surgeon revised the competitor head to a medacta head on (b)(6) 2024.On (b)(6) 2024 the patient had pain due to a dislocation of the medacta head from the competitor liner.The surgeon revised the medacta head with another medacta head and revised the competitor liner with another competitor liner.The surgery was completed successfully.
Additional Manufacturer Narrative
Batch review performed on 19 december 2024.Lot 2102840: (b)(4) items manufactured and released on 09-jun-2021.Expiration date: 2026-05-27.No anomalies found related to the problem.To date, (b)(4) items of the same lot have been sold with one similar reported event during the period of review.There is no indication that any potential issue with the device may have caused or contributed to the event, and the device history record review does not indicate any potential manufacturing related issue.

• Brand Name: COCR FEMORAL BALL HEAD
• Common Device Name: BALL HEADS: COCR 01.25.033 COCR BALL HEAD 12/14 Ø 36 SIZE XL +7
• 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: 21166549
• Report Number: 3005180920-2024-01129
• Device Sequence Number: 21171254
• Product Code: JDI
• UDI-Device Identifier: 07630030805233
• UDI-Public: 07630030805233
• Combination Product (Y/N): N
• Initial Reporter State: MO
• Initial Reporter Country: US
• PMA/510(K) Number: K080885
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2024
• 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): 01/16/2025

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 Expiration Date: 05/27/2026
• Device Model Number: 01.25.033
• Device Lot Number: 2102840
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 12/17/2024
• Initial Report FDA Received Date: 01/16/2025
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 06/09/2021
• 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: Unknown