MAUDE Adverse Event Report: MICROPORT ORTHOPEDICS INC. PROFEMUR NECK NEUTRAL LONG COBALT CHROME; HIP COMPONENT

Model Number	PHAC1204
Medical Device Problem Code	Insufficient Device Problem Information (3190)
Health Effect - Clinical Codes	Reaction (2414); Metal Related Pathology (4530)
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
This event will be updated when investigation is complete.
Event or Problem Description
Allegedly the patient was revised due to mom complications.Left hip.
Additional Manufacturer Narrative
Updated section b5, e1, f and h6.Correction on aware date, incident description and initial reporter.Updated event and evaluation codes.
Event or Problem Description
Allegedly the patient was revised due to mom complications: high cocr ion levels.Left hip.

• Brand Name: PROFEMUR NECK NEUTRAL LONG COBALT CHROME
• Common Device Name: HIP COMPONENT
• Manufacturer (Section D): MICROPORT ORTHOPEDICS INC.; 5677 airline rd.; arlington TN 38002
• MDR Report Key: 9150827
• Report Number: 3010536692-2019-01071
• Device Sequence Number: 1825467
• Product Code: JDL
• UDI-Device Identifier: M684PHAC12041
• UDI-Public: M684PHAC12041
• Combination Product (Y/N): N
• Initial Reporter State: UT
• Initial Reporter Country: US
• PMA/510(K) Number: K091423
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2010
• Device Explanted Year: 2019
• Reporter Type: Manufacturer
• Report Source: distributor,health profession
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 11/23/2020

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: Other
• Device Model Number: PHAC1204
• Device Catalogue Number: PHAC1204
• Device Lot Number: 08977193001
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 08/29/2019
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 09/06/2019
• Supplement Date Received by Manufacturer: 08/29/2019
• Initial Report FDA Received Date: 10/03/2019
• Supplement Report FDA Received Date: 11/23/2020
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 79 YR