MAUDE Adverse Event Report: ENCORE MEDICAL L.P. FMP HIP; HEAD, FEMORAL, COCR 28/+7MM

Model Number	497-28-700
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	12/27/2018
Type of Reportable Event	Serious Injury
Event or Problem Description
Second revision surgery - due to dislocation.
Additional Manufacturer Narrative
The reason for this second revision surgery was dislocaiton.The previous surgery and the revision detailed in this investigation occurred over 12 days apart.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.Initial or prolonged hospitalization was required.This investigation is limited in scope as limited information was provided to djo surgical - austin for examination and the part associated with this investigation was not returned to djo surgical for review.A review of the implant device history records (dhr) shows that the reported components used in the previous surgery met design and manufacturing requirements.There were no non-conforming material reports associated with the product that may have contributed to the event.The device and its applicable concomitant devices were within their respective expiration dates 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 due to dislocation.There were no findings during this investigation that indicate that the reported device was the source or had a direct connection with the event.There are multiple factors that may contribute to the event that are outside the control of djo surgical are inadequate soft tissue, patient bone deterioration, excessive range of motion, patient activities or trauma.Due to the short time between previous and revision surgery, it is also possible that the event may have been occurred due to improper implant selection or patient non-compliance with medical instructions.No additional information was submitted with the complaint regarding pre-existing conditions of the patient or any activities that may have contributed to the event and hence a definitive root cause cannot be determined.There are no indications of a product or process issue affecting implant safety or effectiveness.

• Brand Name: FMP HIP
• Common Device Name: HEAD, FEMORAL, COCR 28/+7MM
• Manufacturer (Section D): ENCORE MEDICAL L.P.; 9800 metric blvd; austin TX 78758 5445
• MDR Report Key: 8254774
• Report Number: 1644408-2019-00039
• Device Sequence Number: 13931357
• Product Code: LPH
• UDI-Device Identifier: 00888912087292
• UDI-Public: (01)00888912087292
• Combination Product (Y/N): N
• Initial Reporter State: FL
• Initial Reporter Country: US
• PMA/510(K) Number: K932481
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2018
• 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: 03/24/2022
• Device Model Number: 497-28-700
• Device Catalogue Number: 497-28-700
• Device Lot Number: 635C1141
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 12/27/2018
• Supplement Date Received by Manufacturer: 01/25/2019
• Initial Report FDA Received Date: 01/16/2019
• 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
• Concomitant Medical Products and Therapy/Usage Dates: 412-02-047, LOT 993B1091
• Outcome Attributed to Adverse Event: Hospitalization; Required Intervention
• Patient Age: 76 YR