MAUDE Adverse Event Report: MICROPORT ORTHOPEDICS INC. DYNASTY® BF SHELL 48MM GROUP B; HIP COMPONENT

Model Number	DSBFGB48
Medical Device Problem Code	Insufficient Device Problem Information (3190)
Health Effect - Clinical Code	Bone Fracture(s) (1870)
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The complaint will be updated once the investigation is completed.Trends will be evaluated.
Event or Problem Description
Allegedly the patient underwent thr on (b)(6) 2019, revised on (b)(6) 2019 due to peri-prosthetic fracture.Revising surgeon believes fracture was caused intra-operatively.No x-rays available.All mpo components were replaced with another manufacture's system.
Event or Problem Description
Allegedly the patient underwent thr on (b)(6) 2019, revised on (b)(6) 2019 due to peri-prosthetic fracture.Revising surgeon believes fracture was caused intra-operatively.No x-rays available.

• Brand Name: DYNASTY® BF SHELL 48MM GROUP B
• Common Device Name: HIP COMPONENT
• Manufacturer (Section D): MICROPORT ORTHOPEDICS INC.; 5677 airline rd.; arlington TN 38002
• MDR Report Key: 8623392
• Report Number: 3010536692-2019-00768
• Device Sequence Number: 13866848
• Product Code: JDL
• UDI-Device Identifier: M684DSBFGB481
• UDI-Public: M684DSBFGB481
• Combination Product (Y/N): N
• Initial Reporter Country: AU
• PMA/510(K) Number: K082924
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2019
• Device Explanted Year: 2019
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 02/12/2020

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 Model Number: DSBFGB48
• Device Catalogue Number: DSBFGB48
• Device Lot Number: 1764239
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 05/13/2019
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 05/13/2019
• Supplement Date Received by Manufacturer: 05/13/2019
• Initial Report FDA Received Date: 05/20/2019
• Supplement Report FDA Received Date: 02/12/2020
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 82 YR