MAUDE Adverse Event Report: SMITH & NEPHEW ORTHOPAEDICS AG POLARCUP XLPE INSERT 53/28 NON-CEM; PROSTHESIS, HIP, SEMI-CONSTRAINED, METAL/POLYMER, POROUS UNCEMENTED

Catalog Number	75018958
Medical Device Problem Code	Device Dislodged or Dislocated (2923)
Health Effect - Clinical Code	Injury (2348)
Date of Event	07/30/2019
Type of Reportable Event	Serious Injury
Event or Problem Description
A revision surgery was reported as the thr presented a cement mantle and the femoral head was dislocating from the acetabular.Polarcup was not dislocating but the femoral head and polar insert was punching off the femoral stem.
Additional Manufacturer Narrative
It was reported that a revision surgery was conducted due to dislocation.The complained device has not been returned for investigation.The device could therefore not be evaluated and the stated failure mode not independently be confirmed.No medical documents were received for investigation.Without supporting clinical/medical documents, a thorough investigation could not be performed.A review of the batch record revealed no deviations from the standard manufacturing process and a review of the complaint history revealed no similar complaints for the device in question.Based on available information, there is no indication that the devise did not meet specification at the time of manufacturing.However, the root cause cannot clearly be identified and stays undetermined.The need for corrective action is not indicated.Nevertheless, s+n will continue to monitor the device for similar issues.The complaint will be reopened should additional information become available.

• Brand Name: POLARCUP XLPE INSERT 53/28 NON-CEM
• Common Device Name: PROSTHESIS, HIP, SEMI-CONSTRAINED, METAL/POLYMER, POROUS UNCEMENTED
• Manufacturer (Section D): SMITH & NEPHEW ORTHOPAEDICS AG; schachenallee 29; baar 06340 ; SZ 06340
• MDR Report Key: 8946017
• Report Number: 9613369-2019-00059
• Device Sequence Number: 2520897
• Product Code: LPH
• UDI-Device Identifier: 07611996111484
• UDI-Public: 07611996111484
• Combination Product (Y/N): N
• Initial Reporter Country: AS
• PMA/510(K) Number: K110135
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Explanted Year: 2019
• Reporter Type: Manufacturer
• Report Source: foreign,health professional,u
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 10/10/2019

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: 11/20/2025
• Device Catalogue Number: 75018958
• Device Lot Number: B1820934
• Initial Date Received by Manufacturer: 07/31/2019
• Supplement Date Received by Manufacturer: 07/31/2019
• Initial Report FDA Received Date: 08/29/2019
• Supplement Report FDA Received Date: 10/10/2019
• 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: Hospitalization; Required Intervention