MAUDE Adverse Event Report: MICROPORT ORTHOPEDICS INC. DYNASTY® BF SHELL PRIMARY 58MM GROUP G; HIP COMPONENT

Model Number	DBFPGG58
Medical Device Problem Code	Insufficient Device Problem Information (3190)
Health Effect - Clinical Code	No Information (3190)
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
This event will be updated when investigation is complete.
Event or Problem Description
Allegedly, patient revised due to unknown complications.
Additional Manufacturer Narrative
Please void this report.Additional information for this incident has made changed the reportability of this incident.This product has no alleged deficiency against this product.This incident is now captured under medwatch 3010536692-2019-00823.The initial report for medwatch 3010536692-2019-00826 should be voided.

• Brand Name: DYNASTY® BF SHELL PRIMARY 58MM GROUP G
• Common Device Name: HIP COMPONENT
• Manufacturer (Section D): MICROPORT ORTHOPEDICS INC.; 5677 airline rd.; arlington TN 38002
• MDR Report Key: 8708386
• Report Number: 3010536692-2019-00826
• Device Sequence Number: 2073493
• Product Code: JDI
• UDI-Device Identifier: M684DBFPGG581
• UDI-Public: M684DBFPGG581
• Combination Product (Y/N): N
• Initial Reporter State: FL
• Initial Reporter Country: US
• PMA/510(K) Number: K122382
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2015
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 02/06/2020

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: No
• Operator of Device: Other
• Device Model Number: DBFPGG58
• Device Catalogue Number: DBFPGG58
• Device Lot Number: 1561788
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 05/20/2019
• Initial Date Received by Manufacturer: 05/20/2019
• Supplement Date Received by Manufacturer: 05/20/2019
• Initial Report FDA Received Date: 06/18/2019
• Supplement Report FDA Received Date: 02/06/2020
• Patient Sequence Number: 1