MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS, INC. 1818910 AML 18.0 MMA 6.3 5/8 STD 12/14; AML IMPLANT : HIP FEMORAL STEM

Catalog Number	155707000
Medical Device Problem Code	Loss of Osseointegration (2408)
Health Effect - Clinical Codes	Calcium Deposits/Calcification (1758); Foreign Body Reaction (1868); Pain (1994); Loss of Range of Motion (2032); Scar Tissue (2060); Injury (2348); Joint Disorder (2373); Inadequate Osseointegration (2646); No Code Available (3191)
Date of Event	10/20/2010
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Product complaint # (b)(4).Initial reporter occupation: lawyer.(b)(4).If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.
Event or Problem Description
Pinnacle claim submission form and medical records received.After review medical records the patient was revised to address pain, extensive heterotopic bone formation, motion of the femoral component and foreign body reaction.Revision notes reported, extensive scar tissue and heterotopic bone formation infiltrating into the gluteus medius and minimus.The femoral component did not appear to be any bone ingrowth on the implant, but there is extensive scar growth.There was granulation tissue within the acetabular cavity, limited range of motion and leg length discrepancy.Surgical pathology report benign, irregular fragment of trabecular bone with fibrosis of the acetabular tissue, foreign body and bone fragment.Doi: (b)(6) 2002; dor: (b)(6) 2010, left hip.
Additional Manufacturer Narrative
Product complaint # (b)(4).Investigation summary = > no device associated with this report was received for examination.A worldwide complaint database search found no other related reported incidents against the provided product code/lot number combination since release for distribution.Based on previous investigations, this complication of joint replacement is unlikely to have been the result of a device failing to meet required specifications.The information received will be retained for potential series investigations if triggered by trend analysis, post market surveillance, or other events within the quality system.If information is obtained that was not available for the initial medwatch, a follow-up medwatch, a follow-up medwatch will be filed as appropriate.

• Brand Name: AML 18.0 MMA 6.3 5/8 STD 12/14
• Common Device Name: AML IMPLANT : HIP FEMORAL STEM
• Manufacturer (Section D): DEPUY ORTHOPAEDICS, INC. 1818910; 700 orthopaedic drive; warsaw IN 46582 0988
• MDR Report Key: 8809035
• Report Number: 1818910-2019-98863
• Device Sequence Number: 16224989
• Product Code: LPH
• UDI-Device Identifier: 10603295059288
• UDI-Public: 10603295059288
• Combination Product (Y/N): N
• Initial Reporter State: TX
• Initial Reporter Country: US
• PMA/510(K) Number: K953694
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2002
• Device Explanted Year: 2010
• Reporter Type: Manufacturer
• Report Source: other
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 06/28/2019

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?: Yes
• Operator of Device: Health Professional
• Device Catalogue Number: 155707000
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 06/28/2019
• Supplement Date Received by Manufacturer: 07/25/2019
• Initial Report FDA Received Date: 07/19/2019
• Supplement Report FDA Received Date: 07/25/2019
• 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: 53 YR