MAUDE Adverse Event Report: DEPUY IRELAND BI MENTUM ALTRX LNR 53 28; HIP IMPLANT - ACETABULAR LINER

Catalog Number	122128053
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Purulent Discharge (1812); Foreign Body Reaction (1868); Hypersensitivity/Allergic reaction (1907); Unspecified Infection (1930); Pain (1994); Pocket Erosion (2013); Osteolysis (2377)
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Product complaint:(b)(4) depuy synthes is submitting this report pursuant to the provisions of 21 cfr, part 803.This report may be based on information which depuy synthes has not been able to investigate or verify prior to the required reporting date.This report does not reflect a conclusion by fda, depuy synthes or its employees that the report constitutes an admission that the device, depuy synthes, or its employees caused or contributed to the potential event described in this report.If the information is unknown, not available or does not apply, the section/field of the form is left blank.If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.
Event or Problem Description
It was reported on february 15, 2012, the patient received a right anterior approach total hip arthroplasty to address right hip osteoarthritis.Metal on metal implants were implanted.There were no complications.On (b)(6) 2024, patient's right hip was revised to address alval pseudotumor, metallosis, osseus bone erosions, and osteolysis.The metal insert and head were replaced with a dual mobility liner construct.There were no complications.On (b)(6) 2024, the patient's right hip was revised again to address purulent wound drainage, possible infection versus alval lesion.Cultures obtained were inconsistent with infection, so the diagnosis leaned in favor of alval, subsequent to the previous revision.Surgeon revised and replaced the femoral head and the dual mobility metal and poly liners, retaining the acetabular cup and femoral stem.And extensive irrigation and debridement were performed.There were no complications.This report captures the revision procedure on (b)(6) 2024.The previous revision is captured on related complaint (b)(4).Doi: (b)(6) 2012 doi: (b)(6) 2024 doe: (b)(6) 2024.
Additional Manufacturer Narrative
Product complaint # (b)(4).Investigation summary: no device associated with this report was received for examination.Product description: - bi mentum altrx lnr 53 28.Product code: - 122128053.Lot no: - 3985318.Quantity of manufactured: - (b)(4).Date of manufacturing: - 31-oct-2022.Expiry date: - 30-sep-2027.As part of our company quality system process, all devices are manufactured, inspected, and distributed to approved specifications.Additional complaint information monitoring for potential safety signals will be conducted through complaint trending as part of the post-market surveillance.If additional information is made available, the investigation will be updated as applicable.Device history lot: product description: - bi mentum altrx lnr 53 28.Product code: - 122128053.Lot no: - 3985318.Quantity of manufactured: - (b)(4).Date of manufacturing: - 31-oct-2022.Expiry date: - 30-sep-2027.Device history review: a manufacturing record evaluation was performed for the finished device, and no non-conformances / manufacturing irregularities related to the malfunction were identified.

• Brand Name: BI MENTUM ALTRX LNR 53 28
• Common Device Name: HIP IMPLANT - ACETABULAR LINER
• Manufacturer (Section D): DEPUY IRELAND; loughbeg ringaskiddy co.; cork ; EI
• Manufacturer (Section G): LEEDS MFG & MATERIAL WAREHOUSE; st anthonys road; leeds LS11 8DT; UK LS11 8DT
• Manufacturer Contact: elba bello ; 700 orthopaedic dr.; warsaw, IN 46581 ; 9083863534
• MDR Report Key: 22161562
• Report Number: 1818910-2025-09271
• Device Sequence Number: 7422055
• Product Code: LZO
• UDI-Device Identifier: 10603295525240
• UDI-Public: (01)10603295525240(17)270930(10)3985318
• Combination Product (Y/N): N
• Initial Reporter State: CA
• Initial Reporter Country: US
• PMA/510(K) Number: K203532
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2024
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Consumer,Health Professional,Company Representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup

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 Catalogue Number: 122128053
• Device Lot Number: 3985318
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 05/15/2025
• Supplement Date Received by Manufacturer: 06/17/2025
• Initial Report FDA Received Date: 06/06/2025
• Supplement Report FDA Received Date: 06/18/2025
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 10/31/2022
• 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
• Concomitant Medical Products and Therapy/Usage Dates: APEX HOLE ELIM POSITIVE STOP.; CORAIL2 LAT COXA VARA SIZE 14.; DELTA CER HEAD 12/14 28MM +5.; PINN CAN BONE SCREW 6.5MMX15MM.; PINN CAN BONE SCREW 6.5MMX15MM.; PINN CAN BONE SCREW 6.5MMX45MM.; PINNACLE DM LINER 62_53.
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Sex: Male