MAUDE Adverse Event Report: OMNILIFE SCIENCE OMNI HIP; PROSTHESIS, HIP, SEMI-CONSTRAINED

Catalog Number	H3-53200
Medical Device Problem Code	Implant subsidence (4078)
Health Effect - Clinical Code	Appropriate Clinical Signs, Symptoms and Conditions Term/Code Not Available (4581)
Date of Event	01/08/2026
Type of Reportable Event	Serious Injury
Event or Problem Description
A complaint was initiated for a patient who underwent a hip revision surgery on (b)(6) 2026.The original surgery date was (b)(6) 2025.The reason for revision reported is subsided stem.During the revision a corin icona stem, and an omnihip femoral head was removed and replaced with new components.
Additional Manufacturer Narrative
The complainant made no indication of any omnilife science device malfunction or deficiency related to the identity, quality, durability, reliability, safety, effectiveness or device performance contributing to the adverse event.Review of the manufacturing documentation and sterilization documentation for the devices in question revealed no deviation from process or non-conformity of product that would have caused or contributed to the adverse event.The submission of this report does not constitute an admission that the device, reporting entity, entity's representative or distributor caused or contributed to this event.

• Brand Name: OMNI HIP
• Common Device Name: PROSTHESIS, HIP, SEMI-CONSTRAINED
• Manufacturer (Section D): OMNILIFE SCIENCE; 480 paramount dr; raynham MA
• Manufacturer (Section G): OMNILIFE SCIENCE; 480 paramount dr; raynham MA
• Manufacturer Contact: jamie demedeiros ; 480 paramount dr; raynham, MA 02767
• MDR Report Key: 24108864
• Report Number: 1226188-2026-00004
• Device Sequence Number: 20303280
• Product Code: LZO
• UDI-Device Identifier: 00841690119234
• UDI-Public: 00841690119234
• Combination Product (Y/N): N
• Initial Reporter State: WI
• Initial Reporter Country: US
• PMA/510(K) Number: K101451
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2025
• Device Explanted Year: 2026
• 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): 01/19/2026

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: H3-53200
• Device Lot Number: 32287
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 01/09/2026
• Initial Report FDA Received Date: 01/19/2026
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 01/24/2019
• 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: Hospitalization; Required Intervention
• Patient Age: 76 YR
• Patient Sex: Female