MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS INC US 6IN AML LRG STATURE 10.5 MM; AML IMPLANT : HIP FEMORAL STEM

Catalog Number	155402106
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Abscess (1690); Cellulitis (1768); Bone Fracture(s) (1870); Unspecified Infection (1930); Pain (1994); Seroma (2069); Limited Mobility Of The Implanted Joint (2671); No Code Available (3191)
Date of Event	12/18/2008
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
(b)(4).Initial reporter occupation: lawyer.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
Patient was revised to address infection (right side).Doi: (b)(6) 2008 - dor: (b)(6) 2008.Update ad 11 apr 2019: (b)(4) has been re-opened under (b)(4) due to pinnacle claim submission form and medical records received.After review of medical records the patient was revised due to infection of right tha, decrease mobility, pain, hip abscess, hip popping and cellulitis.Operative note reported a lesion were debrided, infection is in the hip joint proper and had a cracked proximal femur.Added manufacturing date, expiration date, patient demographics, medical history and patient harm.Corrected patient identifier.Doi: (b)(6) 2008; dor: (b)(6) 2008; right hip.
Additional Manufacturer Narrative
Depuy synthes is submitting this report pursuant to the provision of 21 cfr, part 803.The report may be based on the information which depuy synthes has not been able to investigate or verify prior to the required reporting date.This report does not reflect a conclusion by fda, depuy synthes or its employees that the report constitutes an admission that the device, depuy synthes, or its employees caused or contributed to the potential event described in this report.Product complaint # (b)(4).Investigation summary = > no device associated with this report was received for examination.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.Depuy considers the investigation closed.Should additional information be received, the information will be reviewed and the investigation will be re-opened as necessary.If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.

• Brand Name: 6IN AML LRG STATURE 10.5 MM
• Common Device Name: AML IMPLANT : HIP FEMORAL STEM
• Manufacturer (Section D): DEPUY ORTHOPAEDICS INC US; 700 orthopaedic drive; warsaw IN 46581 0988
• MDR Report Key: 8946759
• Report Number: 1818910-2019-102557
• Device Sequence Number: 14276612
• Product Code: LPH
• UDI-Device Identifier: 10603295058335
• UDI-Public: 10603295058335
• Combination Product (Y/N): N
• Initial Reporter State: TX
• Initial Reporter Country: US
• PMA/510(K) Number: K061833
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2008
• Device Explanted Year: 2008
• Reporter Type: Manufacturer
• Report Source: other
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 12/18/2008

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 Catalogue Number: 155402106
• Device Lot Number: B4AJ61000
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 08/09/2019
• Supplement Date Received by Manufacturer: 12/06/2019
• Initial Report FDA Received Date: 08/29/2019
• Supplement Report FDA Received Date: 12/26/2019
• 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: 43 YR
• Patient Weight: 116