MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS INC US PINN SECTOR HA ACET CUP 62MM; PINNACLE HIP SYSTEM : HIP METAL ACETABULAR CUPS

Catalog Number	121712062
Medical Device Problem Code	Naturally Worn (2988)
Health Effect - Clinical Codes	Foreign Body Reaction (1868); Hypersensitivity/Allergic reaction (1907); Pain (1994); Tissue Damage (2104); Osteolysis (2377); No Code Available (3191)
Date of Event	07/01/2016
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
(b)(4).Occupation: lawyer.If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.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.
Event or Problem Description
Complaint description: patient was revised due to osteolysis.Surgery was delayed 10-15 minutes to remove metal liner.Update ad 02 apr 2019: (b)(4) has been re-opened under (b)(4) due to the receipt of medical records received.After review of medical records, patient was revised to address failed right hip replacement with metallosis and pseudotumor.Revision note reported metallosis, capsulitis, pseudotumor, granular metal wear debris around the proximal femur and inferior aspect of the acetabulum, osteolysis and it was also mention that there was no evidence of loosening.Indication note reported pain, x-rays showed osteolysis around the inferior aspect of the cup and proximal femur and wear debris.Added stem and cup due to new allegation reported from medical records.Added new patient code medical device removal; and patient medical history and updated initials.Doi: (b)(6) 2007 - dor: (b)(6) 2016 (right hip) first revision.

• Brand Name: PINN SECTOR HA ACET CUP 62MM
• Common Device Name: PINNACLE HIP SYSTEM : HIP METAL ACETABULAR CUPS
• Manufacturer (Section D): DEPUY ORTHOPAEDICS INC US; 700 orthopaedic drive; warsaw IN 46581 0988
• MDR Report Key: 9591164
• Report Number: 1818910-2020-01862
• Device Sequence Number: 16292501
• Product Code: LPH
• UDI-Device Identifier: 10603295009214
• UDI-Public: 10603295009214
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K0314952
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2007
• Reporter Type: Manufacturer
• Report Source: other
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 07/01/2016

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?: Yes
• Operator of Device: Health Professional
• Device Catalogue Number: 121712062
• Device Lot Number: BA2GE1000
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 12/31/2019
• Initial Report FDA Received Date: 01/15/2020
• 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: 69 YR
• Patient Weight: 60