MAUDE Adverse Event Report: ENCORE MEDICAL L.P. LIMA HIP; REV DISTAL STM, 16X200MM

Model Number	428-16-200
Health Effect - Clinical Code	No Information (3190)
Date of Event	07/17/2018
Type of Reportable Event	Serious Injury
Event or Problem Description
Second revision surgery - due to the stem being loose.The surgeon removed and replaced the stem, head, and sleeve.
Additional Manufacturer Narrative
The reason for this revision surgery was due to a loose stem.The previous revision surgery and the revision detailed in this investigation occurred 3.5 years apart.There is no information in this complaint about any patient injuries, activities, or accidents that may have contributed to the need for this revision surgery.There are no reported pre-existing patient health conditions.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 implant device history records (dhr), shows that the reported component used in the previous surgery, when released for use, met design and manufacturing requirements.There were no non-conforming material reports (ncmrs) associated with the product that may have contributed to the reported event.The device was verified to have gone through an acceptable sterilization process and was within its expiration date at the time of use during the previous surgery.Customer complaint history of the reported device showed no present trends or on-going issues that are in need of review.The root cause of this complaint was a revision surgery due to a loose stem.There were no findings during this investigation that indicate that the reported device was defective.There are multiple factors that may contribute to an event that are outside of the control of djo surgical.Inventory containment is not required as there are no indications of a product or process issue affecting implant safety or effectiveness.

• Brand Name: LIMA HIP
• Common Device Name: REV DISTAL STM, 16X200MM
• Manufacturer (Section D): ENCORE MEDICAL L.P.; 9800 metric blvd; austin TX 78758 5445
• MDR Report Key: 7715151
• Report Number: 1644408-2018-00705
• Device Sequence Number: 996203
• Product Code: LWJ
• UDI-Device Identifier: 00888912081467
• UDI-Public: (01)00888912081467
• Combination Product (Y/N): N
• Initial Reporter State: CA
• Initial Reporter Country: US
• PMA/510(K) Number: K092331
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2015
• Device Explanted Year: 2018
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 08/03/2018

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: 09/28/2019
• Device Model Number: 428-16-200
• Device Catalogue Number: 428-16-200
• Device Lot Number: 1309851
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 07/17/2018
• Supplement Date Received by Manufacturer: 08/02/2018
• Initial Report FDA Received Date: 07/24/2018
• Supplement Report FDA Received Date: 08/03/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: 411-00-700, LOT 932B1900; 428-00-110, LOT 1208676; 497-40-000, LOT 641C1038; 411-00-700, LOT 932B1900; 428-00-110, LOT 1208676; 497-40-000, LOT 641C1038
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 62 YR