MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS INC US SROM*STM LG 36+8L 20X15X225L; S-ROM HIP SYSTEM : HIP FEMORAL STEM

Model Number	56-3120L
Medical Device Problem Code	Degraded (1153)
Health Effect - Clinical Codes	Adhesion(s) (1695); Necrosis (1971); Pain (1994); No Code Available (3191)
Date of Event	11/30/2010
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Product complaint # (b)(4).Initial reporter occupation: lawyer.(b)(4).If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.
Event or Problem Description
Unf and medical records received.After review of medical records, patient was revised to address severe left hip pain.Mri showed a heavy burden of intracapsular particles.Revision notes stated that the patient was noted to have a significant scar tissue, and deep to the fascia, there were large areas of avascular nonviable scar tissue.Large areas of avascular necrotic tissue were removed.The patient was noted to have a large bare areas overlying the greater trochanter and the lateral aspect of the proximal femur.The granulation tissue was also identified around the acetabular component.Extensive black material around the trunnion was noted.It appeared consistent with corrosion.Doi: (b)(6) 2007.Dor: (b)(6) 2010, (left hip).Doi: (b)(6) 2006, (head and liner).This pc is for the second revision of the left hip.Please see (b)(4) for the first revision and (b)(4) for the right 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 has not been able to investigate or verify prior to the required reporting date.This report does not reflect a conclusion by fda, depuy 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.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.If information is obtained that was not available for the initial medwatch, a follow-up medwatch, a follow-up medwatch will be filed as appropriate.

• Common Device Name: S-ROM HIP SYSTEM : HIP FEMORAL STEM
• Manufacturer (Section D): DEPUY ORTHOPAEDICS INC US; 700 orthopaedic drive; warsaw IN 46581 0988
• MDR Report Key: 9928760
• Report Number: 1818910-2020-10242
• Device Sequence Number: 14057367
• Product Code: JDI
• UDI-Device Identifier: 10603295177845
• UDI-Public: 10603295177845
• Combination Product (Y/N): N
• Initial Reporter State: TX
• Initial Reporter Country: US
• PMA/510(K) Number: K851422
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2007
• Reporter Type: Manufacturer
• Report Source: consumer,other
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 03/12/2020

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?: Yes
• Operator of Device: Health Professional
• Device Model Number: 56-3120L
• Device Catalogue Number: 563120L
• Device Lot Number: 2096833
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 03/12/2020
• Supplement Date Received by Manufacturer: 04/28/2020
• Initial Report FDA Received Date: 04/06/2020
• Supplement Report FDA Received Date: 04/29/2020
• 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