MAUDE Adverse Event Report: ENCORE MEDICAL L.P. FMP HIP; LINER, ACETABULAR, FMP CONSTRAINED 28XMP8

Model Number	436-28-008
Health Effect - Clinical Code	Fall (1848)
Date of Event	05/04/2017
Type of Reportable Event	Serious Injury
Event or Problem Description
Revision surgery - due to the patient getting into a fight and falling on his hip causing the liner to break.
Additional Manufacturer Narrative
The reason for this revision surgery the liner broke.The in-vivo length of patient service for the implant was 3.9 years.The healthcare professional indicated there was no delay in surgery and another suitable device was available for use.The revision surgery was completed as intended.The device was disposed of at the hospital and not made available to djo surgical for examination.A review of the device history records (dhrs) revealed no discrepancies or issues with the manufacturing of this part.All critical dimensions, design criteria and specifications in effect at the time the part was manufactured were met.The product complaint report history was reviewed and no trends or on-going issues were deemed as present or in need of review.This event is deemed as non-product related.The root cause for this event was the patient had fell on their hip causing the liner to break.Inventory containment is not required since there are no indications of a product or process issue affecting implant safety or effectiveness.

• Brand Name: FMP HIP
• Common Device Name: LINER, ACETABULAR, FMP CONSTRAINED 28XMP8
• Manufacturer (Section D): ENCORE MEDICAL L.P.; 9800 metric blvd.; austin TX 78758 5445
• MDR Report Key: 6606635
• Report Number: 1644408-2017-00429
• Device Sequence Number: 789254
• Product Code: KWZ
• UDI-Device Identifier: 00888912085717
• UDI-Public: (01)00888912085717
• Combination Product (Y/N): N
• Initial Reporter State: TX
• Initial Reporter Country: US
• PMA/510(K) Number: K023794
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2013
• Device Explanted Year: 2017
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 07/19/2017

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: 02/28/2017
• Device Model Number: 436-28-008
• Device Catalogue Number: 436-28-008
• Device Lot Number: 500C1000
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Initial Date Received by Manufacturer: 05/05/2017
• Supplement Date Received by Manufacturer: 06/20/2017
• Initial Report FDA Received Date: 06/01/2017
• Supplement Report FDA Received Date: 07/19/2017
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 39 YR
• Patient Weight: 107