MAUDE Adverse Event Report: ENCORE MEDICAL L.P. CONSTRAINED LINER; STEM, HIP, POROUS COATED, PRESS FIT, R120 SIZE3

Catalog Number	438-01-003
Health Effect - Clinical Code	No Information (3190)
Date of Event	07/10/2019
Type of Reportable Event	Serious Injury
Event or Problem Description
Revision surgery - due to modular r120 stem having failed/disassociated with the modular femoral neck.Revision surgery was required to prevent further damage to patient.
Additional Manufacturer Narrative
Manufacturer narrative: the reason for this revision surgery was reported as disassociation.The previous surgery and the surgery detailed in this investigation occurred 9.4 years apart.The healthcare professional indicated there was no delay in surgery and another suitable device was available for use.The revision surgery was completed as intended.The device was disposed of at the hospital and not made available to djo surgical for examination.A review of the implant device history records (dhr) shows that the reported components used in the previous surgery, when released for use, met design and manufacturing requirements.There were no non-conforming material reports (ncmr) associated with the products that may have contributed to the reported event.The devices was verified to have gone through an acceptable sterilization process and was within its expiration date at the time of the previous surgery.Customer complaint history of the reported device showed no present trends or on-going issues that are in need of review.The root cause of this complaint was a revision surgery due to disassociation.There were no findings during this investigation that indicate that the reported device was defective.No information was submitted with the complaint regarding pre-existing conditions of the patient or any activities the patient was involved in that may have contributed to the event.There are multiple factors that may contribute to an event that are outside the control of djo surgical.There are no indications of a product or process issue affecting implant safety or effectiveness.

• Brand Name: CONSTRAINED LINER
• Common Device Name: STEM, HIP, POROUS COATED, PRESS FIT, R120 SIZE3
• Manufacturer (Section D): ENCORE MEDICAL L.P.; 9800 metric blvd; austin, tx 78758-5445 TX 78758 5445
• MDR Report Key: 8874101
• Report Number: 1644408-2019-00760
• Device Sequence Number: 14100211
• Product Code: KWZ
• UDI-Device Identifier: 00888912085861
• UDI-Public: (01)00888912085861
• Combination Product (Y/N): N
• Initial Reporter State: MN
• Initial Reporter Country: US
• PMA/510(K) Number: K023794
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2010
• Device Explanted Year: 2019
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 09/06/2019

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 Expiration Date: 05/28/2014
• Device Catalogue Number: 438-01-003
• Device Lot Number: 53912678
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 07/10/2019
• Supplement Date Received by Manufacturer: 08/08/2019
• Initial Report FDA Received Date: 08/08/2019
• Supplement Report FDA Received Date: 09/06/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: 400-03-361. LOT 53987283; 410-32-108. LOT 54009869; 931-36-254. LOT 53942404; 400-03-361. LOT 53987283; 410-32-108. LOT 54009869; 931-36-254. LOT 53942404
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 69 YR