MAUDE Adverse Event Report: MICROPORT ORTHOPEDICS INC. DYNASTY® A-CLASS® 15DG POLY LINER 36MM GROUP G; HIP COMPONENT

Model Number	DLXPLG36
Medical Device Problem Code	Device Dislodged or Dislocated (2923)
Health Effect - Clinical Code	No Information (3190)
Type of Reportable Event	Serious Injury
Event or Problem Description
Allegedly, patient was revised due to the patient dislocating.All components removed, replaced with different manufacturers system, apart from the 36mm mpo femoral head, which was removed and replaced with a 28mm mpo femoral head.(b)(6).

• Brand Name: DYNASTY® A-CLASS® 15DG POLY LINER 36MM GROUP G
• Common Device Name: HIP COMPONENT
• Manufacturer (Section D): MICROPORT ORTHOPEDICS INC.; 5677 airline rd.; arlington TN 38002
• MDR Report Key: 9577184
• Report Number: 3010536692-2020-00030
• Device Sequence Number: 2224858
• Product Code: JDI
• UDI-Device Identifier: M684DLXPLG361
• UDI-Public: M684DLXPLG361
• Combination Product (Y/N): N
• Initial Reporter Country: AU
• PMA/510(K) Number: K070785
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2019
• Device Explanted Year: 2019
• Reporter Type: Manufacturer
• Report Source: distributor
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 01/10/2020

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: Health Professional
• Device Model Number: DLXPLG36
• Device Catalogue Number: DLXPLG36
• Device Lot Number: 1749008
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 10/15/2019
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 10/15/2019
• Initial Report FDA Received Date: 01/10/2020
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 79 YR