MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS, INC.1818910 PINNACLE 100 HA ACET CUP 52MM; HIP ACETABULAR CUP

Catalog Number	121711052
Medical Device Problem Code	Disassembly (1168)
Health Effect - Clinical Code	No Information (3190)
Date of Event	07/17/2017
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 disassociation.Update 7-25-2017: medical records have been reviewed.Primary operative notes (b)(6) 2008 indicate the patient received a corail cementless metal on polyethylene left total hip arthroplasty due to osteoarthritis left hip.The procedure was completed without any complication noted by the surgeon.Reportability remains unchanged.Updated 8-14-2017.
Additional Manufacturer Narrative
The patient was revised to address disassociation.The reported event has been evaluated and will be monitored.Depuy considers the investigation closed at this time.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: PINNACLE 100 HA ACET CUP 52MM
• Common Device Name: HIP ACETABULAR CUP
• Manufacturer (Section D): DEPUY ORTHOPAEDICS, INC.1818910; 700 orthopaedic drive; warsaw IN 46582
• MDR Report Key: 6793750
• Report Number: 1818910-2017-22724
• Device Sequence Number: 19272467
• Product Code: LPH
• UDI-Device Identifier: 10603295009061
• UDI-Public: 10603295009061
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K031495
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2008
• Device Explanted Year: 2017
• Reporter Type: Manufacturer
• Report Source: foreign,health professional
• Initial Reporter Occupation: Health Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 07/17/2017

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: 121711052
• Device Lot Number: CB9JS1000
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 07/17/2017
• Supplement Date Received by Manufacturer: 10/08/2017
• Initial Report FDA Received Date: 08/15/2017
• Supplement Report FDA Received Date: 10/13/2017
• 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: 85 YR
• Patient Weight: 86