MAUDE Adverse Event Report: DEPUY CMW¿ 9610921 CEMENT RESTRICTOR SIZE 4; CEMENT / CEMENT ACCESSORY

Catalog Number	546016000
Medical Device Problem Codes	Disassembly (1168); Malposition of Device (2616)
Health Effect - Clinical Code	No Information (3190)
Date of Event	08/07/2017
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 loosening of the stem.Loosening occured at implant to cement interface.Depuy cement was used.
Additional Manufacturer Narrative
The patient was revised to address loosening of the stem.Loosening occured at implant to cement interface.Depuy cement was used.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: CEMENT RESTRICTOR SIZE 4
• Common Device Name: CEMENT / CEMENT ACCESSORY
• Manufacturer (Section D): DEPUY CMW¿ 9610921; cornford rd; blackpool FY4 4 QQ; UK FY4 4QQ
• MDR Report Key: 6846244
• Report Number: 1818910-2017-24131
• Device Sequence Number: 65790
• Product Code: HRY
• UDI-Device Identifier: 10603295174356
• UDI-Public: 10603295174356
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K940743
• 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,foreig
• Initial Reporter Occupation: Health Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 08/07/2017

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: 546016000
• Device Lot Number: 694313
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 08/07/2017
• Supplement Date Received by Manufacturer: 11/10/2017
• Initial Report FDA Received Date: 09/06/2017
• Supplement Report FDA Received Date: 11/10/2017
• 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: 80 YR