MAUDE Adverse Event Report: MICROPORT ORTHOPEDICS INC. CONSERVE® A-CLASS® BFH® HEAD MEDIUM NECK 40MM; HIP COMPONENT

Model Number	38AM4000
Medical Device Problem Code	Material Disintegration (1177)
Health Effect - Clinical Code	Reaction (2414)
Type of Reportable Event	Serious Injury
Event or Problem Description
Allegedly the patient was revised due to mom complications: metallosis; pseudo-tumor.(left).Liner and head were removed and replaced with a ceramic head and poly liner (36mm).

• Brand Name: CONSERVE® A-CLASS® BFH® HEAD MEDIUM NECK 40MM
• Common Device Name: HIP COMPONENT
• Manufacturer (Section D): MICROPORT ORTHOPEDICS INC.; 5677 airline rd.; arlington TN 38002
• MDR Report Key: 8754945
• Report Number: 3010536692-2019-00889
• Device Sequence Number: 2043620
• Product Code: KWA
• UDI-Device Identifier: M68438AM40001
• UDI-Public: M68438AM40001
• Combination Product (Y/N): N
• Initial Reporter State: UT
• Initial Reporter Country: US
• PMA/510(K) Number: K021349
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2010
• Device Explanted Year: 2019
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 07/02/2019

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 Model Number: 38AM4000
• Device Catalogue Number: 38AM4000
• Device Lot Number: 089924907
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 07/02/2019
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 06/28/2019
• Initial Report FDA Received Date: 07/02/2019
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention