MAUDE Adverse Event Report: ENCORE MEDICAL L.P. CONSTRAINED LINER; LINER, LOCKING RING, CONSTRAINED

Model Number	436-28-000
Health Effect - Clinical Code	No Information (3190)
Date of Event	08/14/2019
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The reason for this revision surgery was reported as locking ring broke.The previous surgery and the surgery detailed in this investigation occurred over 11.7 months apart.Initial or prolonged hospitalization was required.The healthcare professional indicated there was a serious risk to the patient.There was no delay in surgery and another suitable device was available for use.The revision surgery was completed as intended.The device was returned to manufacturer and device evaluation anticipated, but not yet begun in djo surgical for examination.A review of the device history records (dhr) show 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 devices showed no present trends or on-going issues that are needing a review.The root cause of this complaint was a revision surgery due to locking ring broke.There were no findings during this evaluation 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 of the control of djo surgical.There are no indications of a product or process issue affecting implant safety or effectiveness.
Event or Problem Description
Second revision surgery - the ring or acetabular liner dislodged and broke.Either ring might have became loose causing the plastic to break or the plastic might have broken causing the ring to loose.

• Brand Name: CONSTRAINED LINER
• Common Device Name: LINER, LOCKING RING, CONSTRAINED
• Manufacturer (Section D): ENCORE MEDICAL L.P.; 9800 metric blvd; austin, tx 78758-5445
• MDR Report Key: 9013751
• Report Number: 1644408-2019-00863
• Device Sequence Number: 13899274
• Product Code: KWZ
• UDI-Device Identifier: 00888912085663
• UDI-Public: (01)00888912085663
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K023794
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2018
• Device Explanted Year: 2019
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 09/10/2019

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: 05/24/2023
• Device Model Number: 436-28-000
• Device Catalogue Number: 436-28-000
• Device Lot Number: 496C1071
• Was Device Available for Evaluation?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 08/14/2019
• Initial Report FDA Received Date: 09/12/2019
• 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; Other; Required Intervention
• Patient Age: 77 YR
• Patient Weight: 77