MAUDE Adverse Event Report: ENCORE MEDICAL L.P. FMP HIP; LINER, LOCKING RING, CONSTRAINED

Model Number	436-28-000
Health Effect - Clinical Code	No Code Available (3191)
Date of Event	11/21/2018
Type of Reportable Event	Serious Injury
Event or Problem Description
Second revision surgery - reason unknown.
Additional Manufacturer Narrative
The reason for this second revision surgery was unknown/not reported.If additional information regarding the reported event is submitted at a future date, this investigation will be re-evaluated.The previous surgery and the surgery detailed in this investigation occurred 1.5 years apart.There was no delay in surgery and another suitable device was available for use.The revision surgery was completed as intended.This investigation is limited in scope as the item(s) associated with this investigation was not returned to djo surgical - (b)(4) for examination.A review of the implant device history records (dhr), shows that the reported component(s) used in the previous surgery, when released for use, met design and manufacturing requirements.There were no ncmrs associated with the product(s) that may have contributed to the reported event.The device(s) 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(s) showed no present trends or on-going issues that are in need of review.The root cause of this complaint was a revision surgery for unknown reasons.No information was submitted with the complaint regarding pre-existing conditions of the patient or any activities the patient was involved in that may have contributed to the event.There were no findings during this investigation that indicate that the reported device(s) was defective.

• Brand Name: FMP HIP
• Common Device Name: LINER, LOCKING RING, CONSTRAINED
• Manufacturer (Section D): ENCORE MEDICAL L.P.; 9800 metric blvd; austin TX 78758 5445
• MDR Report Key: 8149296
• Report Number: 1644408-2018-01150
• Device Sequence Number: 13516053
• Product Code: KWZ
• UDI-Device Identifier: 00888912085663
• UDI-Public: (01)00888912085663
• Combination Product (Y/N): N
• Initial Reporter State: TX
• Initial Reporter Country: US
• PMA/510(K) Number: K023794
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2017
• 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): 01/29/2019

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: 01/06/2023
• Device Model Number: 436-28-000
• Device Catalogue Number: 436-28-000
• Device Lot Number: 496C1068
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 11/21/2018
• Supplement Date Received by Manufacturer: 01/25/2019
• Initial Report FDA Received Date: 12/10/2018
• Supplement Report FDA Received Date: 01/29/2019
• 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: 41 YR