MAUDE Adverse Event Report: S.E.R.F Societe dEtudes Recherche Fabrication CI 57/28 E DUAL MOBILITY PE LI; prosthesis, hip, semi-constrained, metal/ceramic/polymer, cemented or non-porous

Catalog Number	RM54202857
Medical Device Problem Codes	Degraded (1153); Material Erosion (1214)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	07/21/2026
Type of Reportable Event	Serious Injury
Event or Problem Description
Patient occured a bi-lateral hip revision due to liner erosion and wear of the cup.
Additional Manufacturer Narrative
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.

• Brand Name: CI 57/28 E DUAL MOBILITY PE LI
• Common Device Name: prosthesis, hip, semi-constrained, metal/ceramic/polymer, cemented or non-porous
• Manufacturer (Section D): S.E.R.F Societe dEtudes Recherche Fabrication; 85 avenue des bruyeres; 69150 decines-charpieu; decines 69150 ; FR 69150
• Manufacturer (Section G): S.E.R.F Societe dEtudes Recherche Fabrication; 85 avenue des bruyeres; 69150 decines-charpieu; decines 69150 ; FR 69150
• Manufacturer Contact: margaux baboulaz ; 85 avenue des bruyeres; 69150 decines-charpieu; decines 69150 ; FR 69150 ; +33()472056010
• MDR Report Key: 50714616
• Report Number: 3008668801-2026-00028
• Device Sequence Number: 13435892
• Product Code: LZO
• UDI-Device Identifier: 03662200006014
• UDI-Public: 03662200006014
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K111572
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2017
• Device Explanted Year: 2026
• Reporter Type: Manufacturer
• Report Source: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 09/30/2026

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 Expiration Date: 06/01/2021
• Device Catalogue Number: RM54202857
• Device Lot Number: 1606382A
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Initial Date Received by Manufacturer: 08/31/2026
• Supplement Date Received by Manufacturer: 09/28/2026
• Initial Report FDA Received Date: 09/10/2026
• Supplement Report FDA Received Date: 09/30/2026
• Was Device Evaluated by Manufacturer? (Y/N): No
• 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: 79 YR
• Patient Sex: Male