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

Model Number	DSPCGG58
Medical Device Problem Codes	Material Disintegration (1177); Noise, Audible (3273); Migration (4003)
Health Effect - Clinical Code	Pain (1994)
Type of Reportable Event	Serious Injury
Event or Problem Description
Allegedly the patient was revised due to mom complications: severe hip pain; elevated metal levels of cobalt and chromium; evidence of subsidence of the stem; metallosis; and clicking (right).

• Brand Name: DYNASTY® PC SHELL 58MM GROUP G
• Common Device Name: HIP COMPONENT
• Manufacturer (Section D): MICROPORT ORTHOPEDICS INC.; 5677 airline rd.; arlington TN 38002
• MDR Report Key: 8838391
• Report Number: 3010536692-2019-00922
• Device Sequence Number: 19382251
• Product Code: LZO
• UDI-Device Identifier: M684DSPCGG581
• UDI-Public: M684DSPCGG581
• Combination Product (Y/N): N
• Initial Reporter State: TN
• Initial Reporter Country: US
• PMA/510(K) Number: K061547
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2009
• Device Explanted Year: 2018
• Reporter Type: Manufacturer
• Report Source: consumer
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 07/29/2019

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 Model Number: DSPCGG58
• Device Catalogue Number: DSPCGG58
• Device Lot Number: 049846164
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 07/22/2019
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 07/22/2019
• Initial Report FDA Received Date: 07/29/2019
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Weight: 100