MAUDE Adverse Event Report: DEPUY ORTHOPAEDIC INC, 1818910 DRLC SCR TRL LN NEUT 32ID 60OD; HIP INSTRUMENT/TRIAL

Catalog Number	223820000
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Information (3190)
Date of Event	07/19/2017
Type of Reportable Event	Malfunction
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
It was reported that the screws are broken out of trial.Surgeons are complaining.
Additional Manufacturer Narrative
Product complaint # pc (b)(4).If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.
Additional Manufacturer Narrative
Product complaint :(b)(4).Investigation summary : the device associated with this complaint was not returned. 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.If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.

• Brand Name: DRLC SCR TRL LN NEUT 32ID 60OD
• Common Device Name: HIP INSTRUMENT/TRIAL
• Manufacturer (Section D): DEPUY ORTHOPAEDIC INC, 1818910; 700 orthopaedic drive; warsaw IN 46582 0988
• MDR Report Key: 6801578
• Report Number: 1818910-2017-22987
• Device Sequence Number: 16455727
• Product Code: LXH
• UDI-Device Identifier: 10603295107026
• UDI-Public: 10603295107026
• Combination Product (Y/N): N
• Initial Reporter State: KY
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: distributor
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup,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?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Catalogue Number: 223820000
• Device Lot Number: UNKNOWN
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 06/20/2018
• Initial Date Received by Manufacturer: 07/19/2017
• Supplement Date Received by Manufacturer: 06/20/2018; 06/20/2018
• Initial Report FDA Received Date: 08/17/2017
• Supplement Report FDA Received Date: 06/27/2018; 07/19/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1