MAUDE Adverse Event Report: DEPUY IRELAND - 9616671 5.5X30MM GRIPTION TF STE SCREW; GRIPTION TF AUGMENT : HIP METAL ACETABULAR CUPS

Model Number	1217-30-800
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Hematoma (1884); Hip Fracture (2349); No Code Available (3191)
Date of Event	12/29/2017
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Product complaint # (b)(4).Initial reporter occupation: lawyer.(b)(4).
Event or Problem Description
After review of medical records, it was reported that the patient got up out of bed and tore the acetabular component out, fractured around it.Then the patient was revised for displaced left acetabular component/ periprosthetic fracture.Operative notes reported that about 300 ml hematoma was expelled.The constrained liner was still locked around the prosthetic ball but it had torn the shell out of her native acetabular fossa.Screws has been added to the complaint.Doi: (b)(6) 2017; dor: (b)(6) 2017; left hip.
Additional Manufacturer Narrative
Depuy synthes is submitting this report pursuant to the provisions of 21 cfr, part 803.This report may be based on information which depuy synthes been able to investigate or verify prior to the required reporting date.This report does not reflect a conclusion by fda, depuy as not 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.H10 additional narrative: corrected: h6.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.Device history lot: null.Device history batch: null.Device history review: null.If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.

• Brand Name: 5.5X30MM GRIPTION TF STE SCREW
• Common Device Name: GRIPTION TF AUGMENT : HIP METAL ACETABULAR CUPS
• Manufacturer (Section D): DEPUY IRELAND - 9616671; loughbeg ringaskiddy co.; cork ; EI
• MDR Report Key: 9756397
• Report Number: 1818910-2020-06022
• Device Sequence Number: 1865868
• Product Code: JDI
• UDI-Device Identifier: 10603295381372
• UDI-Public: 10603295381372
• Combination Product (Y/N): N
• Initial Reporter State: CA
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2017
• Device Explanted Year: 2017
• Reporter Type: Manufacturer
• Report Source: consumer,other
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 09/23/2019

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: 12/31/2023
• Device Model Number: 1217-30-800
• Device Catalogue Number: 121730800
• Device Lot Number: 471212
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 02/09/2020
• Supplement Date Received by Manufacturer: 02/27/2020
• Initial Report FDA Received Date: 02/26/2020
• Supplement Report FDA Received Date: 03/02/2020
• 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: 70 YR