| Catalog Number |
7236-2-848 |
| Medical Device Problem Code |
Use of Device Problem (1670)
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| Health Effect - Clinical Code |
No Clinical Signs, Symptoms or Conditions (4582)
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| Date of Event |
03/31/2025
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Type of Reportable Event
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Serious Injury
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Event or Problem Description
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During a total hip replacement, the wrong implant was put into the patient.The surgeon uses our mdm implants and the wrong size/alpha code insert was implanted.For the procedure, it was a 50mm d trident ii clusterhole cup implanted with an alpha code d mdm liner.However, an alpha code e mdm insert was used for the procedure.The issue was identified towards the end of the procedure when the surgeon card was being made by the representative.The surgeon was notified immediately, but the patient was already being awakened.The patient was taken back into surgery to correct the sizing of the implants the following morning.
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Additional Manufacturer Narrative
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Review of the device history records indicate devices were manufactured and accepted into final stock with no relevant reported discrepancies.There have been no similar events for the lot referenced.An evaluation of the device cannot be performed as the device was not returned to the manufacturer.Should additional information become available it will be reported in a supplemental report upon completion of the investigation.
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Additional Manufacturer Narrative
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Reported event: an event regarding incorrect selection - user error issue involving an adm liner was reported.The event was confirmed.Method & results product evaluation and results: material analysis, visual, functional and dimensional inspections could not be performed as the device was not returned.Clinician review: no medical records were received for review with a clinical consultant.Product history review: review of the device history records indicate devices were manufactured and accepted into final stock with no relevant reported discrepancies.Complaint history review: there have been no other similar events for the lot referenced.Conclusion: it was reported that an incorrect insert was implanted.The 42e insert which was implanted was removed the same day, and a 48g insert was implanted.Discovery was made on the same day.The implant sheet was provided with the device label.The reported event is considered to be the result of user error.No further investigation for this event is possible at this time.If additional information becomes available to indicate further evaluation is warranted, this record will be reopened.
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Event or Problem Description
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No new information.
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Search Alerts/Recalls
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