MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS, INC. 1818910 PINN LNR CON +4 10D 40IDX62OD; HIP ACETABULAR INSERT/LINER

Catalog Number	121840762
Medical Device Problem Codes	Fracture (1260); Device Dislodged or Dislocated (2923)
Health Effect - Clinical Code	Joint Dislocation (2374)
Date of Event	06/21/2017
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
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
The patient was revised to address hip dislocation.It was stated that his hip broke which implanted the same surgeon on the same hospital.The patient's initial pinnacle 62mm od x 40mm id +4 10 degree constrained liner was replaced with a pinnacle 62mm od x 40mm id +4 neutral constrained liner.The initial 40mm +5 biolox delta ts femoral head was also replaced with a matching 40mm +5 biolox delta ts femoral head.Update jul 19, 2017: additional information.That the patient had a fractured constrained liner.This complaint was updated on jul 19, 2017.
Additional Manufacturer Narrative
No device associated with this report was received for examination.The information received will be retained for potential series investigations if triggered by trend analysis, post market surveillance, or other events within the quality system.Depuy considers the investigation closed.Should additional information be received, the information will be reviewed and the investigation will be re-opened as necessary.If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.

• Brand Name: PINN LNR CON +4 10D 40IDX62OD
• Common Device Name: HIP ACETABULAR INSERT/LINER
• Manufacturer (Section D): DEPUY ORTHOPAEDICS, INC. 1818910; 700 orthopaedic drive; warsaw IN 46582
• MDR Report Key: 6731195
• Report Number: 1818910-2017-21433
• Device Sequence Number: 1371412
• Product Code: KWZ
• UDI-Device Identifier: 10603295012221
• UDI-Public: 10603295012221
• Combination Product (Y/N): N
• Initial Reporter State: VA
• Initial Reporter Country: US
• PMA/510(K) Number: K071117
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2016
• Device Explanted Year: 2017
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Health Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 06/21/2017

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 Catalogue Number: 121840762
• Device Lot Number: 751760
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 06/21/2017
• Supplement Date Received by Manufacturer: 08/14/2017
• Initial Report FDA Received Date: 07/21/2017
• Supplement Report FDA Received Date: 08/14/2017
• 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: Hospitalization; Required Intervention
• Patient Age: 64 YR