MAUDE Adverse Event Report: STRYKER ORTHOPAEDICS-MAHWAH #4 MOD REV HIP BROACH BDY/BOLTCOMPONENT LEVEL 9006-1-014; HIP JOINT METAL/POLYMER/METAL SEMI-CONSTRAINED POROUS-COATED UNCEMENTED PROSTHES

Catalog Number	6276-3-004
Medical Device Problem Code	Insufficient Device Problem Information (3190)
Health Effect - Clinical Codes	Injury (2348); Reaction (2414)
Date of Event	07/14/2015
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The initial information was provided by legal.No additional information is available at this time due to the ongoing litigation.Should additional information become available, the evaluation summary will be submitted in a supplemental report.A review of the device history records indicates that the reported devices were manufactured and accepted into final stock with no reported discrepancies.The complaint history review indicated that there were no similar events for the reported lot.Not returned to the manufacturer.
Event or Problem Description
It was reported through the filing of a lawsuit that allegedly the patient was implanted with an lfit anatomic cocr v40 femoral head on her right hip on or about (b)(6) 2014 and was revised on (b)(6) 2015.It is further alleged that she suffered injuries as a result of implantation and explantation of the device at issue, device recall, excessive levels of cobalt and chromium in her blood.

• Brand Name: #4 MOD REV HIP BROACH BDY/BOLTCOMPONENT LEVEL 9006-1-014
• Common Device Name: HIP JOINT METAL/POLYMER/METAL SEMI-CONSTRAINED POROUS-COATED UNCEMENTED PROSTHES
• Manufacturer (Section D): STRYKER ORTHOPAEDICS-MAHWAH; 325 corporate drive; mahwah NJ 07430
• MDR Report Key: 7935396
• Report Number: 0002249697-2018-03198
• Device Sequence Number: 941278
• Product Code: LPH
• UDI-Device Identifier: 04546540641540
• UDI-Public: 04546540641540
• Combination Product (Y/N): N
• Initial Reporter State: FL
• Initial Reporter Country: US
• PMA/510(K) Number: K121308
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2014
• Device Explanted Year: 2015
• Reporter Type: Manufacturer
• Report Source: consumer,other
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 10/04/2018

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: 12/30/2018
• Device Catalogue Number: 6276-3-004
• Device Lot Number: 46012401
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 09/06/2018
• Initial Report FDA Received Date: 10/04/2018
• 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