UNKNOWN SHELL
Report
- Report Number
- 3002806535-2023-00444
- Event Type
- Injury
- Date Received
- December 19, 2023
- Date of Event
- November 27, 2023
- Report Date
- May 17, 2024
- Manufacturer
- BIOMET UK LTD.
- Product Code
- LZO
- PMA / PMN Number
- N/A
- Adverse Event
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- BE
- Reporter Occupation
- PHYSICIAN
- Health Professional
- Yes
Narratives
(B)(4). THIS FOLLOW-UP REPORT IS BEING SUBMITTED TO RELAY ADDITIONAL INFORMATION. THE FOLLOWING SECTIONS WERE UPDATED: B4, B7, D10, G3, G6, H2, H11. D10 - ASSOCIATED MEDICAL DEVICES: RINGLOC-X E1 STD 50/32MM 23; ITEM# (B)(6); LOT# 3103574. IF ANY FURTHER INFORMATION IS FOUND WHICH WOULD CHANGE OR ALTER ANY CONCLUSIONS OR INFORMATION, A SUPPLEMENTAL REPORT WILL BE FILED ACCORDINGLY. ZIMMER BIOMET WILL CONTINUE TO MONITOR FOR TRENDS.
(B)(4). THIS FOLLOW-UP REPORT IS BEING SUBMITTED TO RELAY ADDITIONAL INFORMATION. THE FOLLOWING SECTIONS WERE UPDATED: B4, G3, G6, H2, H6, H11. THE CERAMIC HEAD AND POLY LINER WERE RETURNED FOR EVALUATION. A VISUAL INSPECTION OF THE ITEMS WAS UNABLE TO CONFIRM ITEM/LOT INFORMATION ON THE CERAMIC HEAD OR THE LINER. THE SHELL WAS NOT RETURNED WITH THIS COMPLAINT. THE LINER WAS RETURNED DAMAGED AND THE CERAMIC HEAD WAS FRACTURED INTO SEVERAL PIECES WITH NOT ALL OF THE PIECES BEING RETURNED. THERE IS ALSO SOME GALLING ON THE ID OF THE CERAMIC HEAD WHERE THE NECK TAPER WOULD CONTACT THE HEAD. FRACTURE ANALYSIS WAS PERFORMED ON THE RETURNED CERAMIC HEAD. EXAMINATION OF THE FRACTURED HEAD IMAGES PROVIDED SHOWS METAL TRANSFER MARKS WITHIN THE TAPER, AS WELL AS OCCASIONAL METAL TRANSFER MARKS ON OTHER SURFACES, LIKELY FROM CONTACT WITH THE METAL STEM, ACETABULAR SHELL AND/OR FROM CONTACT WITH INSTRUMENTS DURING REMOVAL. THE FRACTURE SURFACES LOOKED IRREGULAR, WITH CLEAN FLAT REGIONS ADJACENT TO ROUGHER SURFACES. THE COMPLEXITY OF THE FRACTURE SURFACES DID NOT ALLOW FOR THE DETERMINATION OF THE FRACTURE INITIATION POINT. THE ROOT CAUSE OF THE CERAMIC HEAD FRACTURE COULD NOT BE DETERMINED IN THIS INSTANCE. A REVIEW OF THE DEVICE MANUFACTURING RECORDS FOR THE CERAMIC HEAD AND POLY LINER CONFIRMED NO ABNORMALITIES OR DEVIATIONS THAT COULD BE RELATED TO THE REPORTED EVENT. A REVIEW OF THE DEVICE MANUFACTURING RECORDS FOR THE ACETABULAR CUP COULD NOT BE PERFORMED DUE TO THE LOT NUMBER BEING UNKNOWN. MEDICAL RECORDS WERE PROVIDED AND REVIEWED BY A HEALTH CARE PROFESSIONAL. THE REVIEW IDENTIFIED THE FOLLOWING: 17 DAYS PRE-REVISION X-RAY REPORT: NO PERIPROSTHETIC FRACTURE, PROSTHETIC FRACTURE OF THE ACETABULAR CUP PROJECTING INFERIOR OF THE PROSTHETIC HEAD, INCREASED HO SUPERIOR OF THE MAJOR TUBERCULUM, INTACT PELVIC RING, MODERATE COXARTHROSIS ON THE LEFT. 10 DAYS PRE-REVISION CT REPORT: FRACTURE OF PROSTHETIC HEAD WITH LOOSE POSTERIOR FRAGMENT, NO DETACHMENT OF STEM, INTACT ACETABULAR CUP AND LINER, SOME HETEROTOPIC OSSIFICATION AROUND THE RIGHT HIP. REVISION OP REPORT: GENERAL + BLOCK. POSTEROLATERAL APPROACH. 2 LARGE FRAGMENTS AND SEVERAL SMALLER CERAMIC FRAGMENTS WERE REMOVED, EXTENSIVE SYNOVECTOMY WITH REMOVAL OF MORE CERAMIC AND POLYETHYLENE FRAGMENTS. STEM WELL FIXED, TAPERLOC SLIGHTLY DAMAGED BUT REMAINED IMPLANTED. LINER WEAR POSTERIORLY WITH PARTIAL BONY OVERGROWTH, CUP WITH PRONOUNCED BONY OVERGROWTH ANTERIORLY THAT MAY HAVE CAUSED IMPINGEMENT. NO COMPLICATIONS - 1 DAY POST REVISION X-RAY REPORT: NORMAL FINDINGS, GOOD AXLE AND POSITION, NO FRACTURE WITH THE AVAILABLE INFORMATION, A DEFINITIVE ROOT CAUSE COULD NOT BE DETERMINED. IF ANY FURTHER INFORMATION IS FOUND WHICH WOULD CHANGE OR ALTER ANY CONCLUSIONS OR INFORMATION, A SUPPLEMENTAL REPORT WILL BE FILED ACCORDINGLY. ZIMMER BIOMET WILL CONTINUE TO MONITOR FOR TRENDS.
(B)(4). THIS FOLLOW-UP REPORT IS BEING SUBMITTED TO RELAY ADDITIONAL AND/OR CORRECTED INFORMATION. D10 - MEDICAL DEVICES: DELTA CER FEM HD 32/0MM T1; ITEM# 650-1162; LOT# 3002597. INVESTIGATION OF THIS INCIDENT IS CURRENTLY ONGOING. ONCE THE INVESTIGATION IS COMPLETED, A SUPPLEMENTAL MEDWATCH 3500A WILL BE SUBMITTED.
(B)(4). G2-FOREIGN-BELGIUM D10. ITEM#: UNKNOWN; LOT#: UNKNOWN; ITEM NAME: DELTA CER FEM HD 32/0MM T1; ITEM#: UNKNOWN; LOT#: UNKNOWN; ITEM NAME: UNKNOWN LINER; ITEM#: UNKNOWN; LOT#: UNKNOWN; ITEM NAME: UNKNOWN TAPERLOC STEM BIOMET; H3-OTHER: DEVICE EVALUATION COULD NOT BE PERFORMED AS PART# AND LOT# UNKNOWN. ALSO DEVICE LOCATION IS UNKNOWN. MULTIPLE MDR REPORTS WERE FILED FOR THIS EVENT, PLEASE SEE THE ASSOCIATED REPORTS: 3002806535 - 2023 - 00437 3002806535 - 2023 - 00443 INVESTIGATION OF THIS INCIDENT IS CURRENTLY ONGOING. ONCE THE INVESTIGATION IS COMPLETED, A SUPPLEMENTAL MEDWATCH 3500A WILL BE SUBMITTED. H3 OTHER TEXT : SEE H10
NO FURTHER EVENT INFORMATION AVAILABLE AT THE TIME OF THIS REPORT.
NO FURTHER EVENT INFORMATION AVAILABLE AT THE TIME OF THIS REPORT.
NO FURTHER EVENT INFORMATION AVAILABLE AT THE TIME OF THIS REPORT.
IT WAS REPORTED THAT THE PATIENT UNDERWENT REVISION SURGERY DUE TO PROSTHETIC FRACTURE AND HETEROTOPIC OSSIFICATION. DUE DILIGENCE IS IN PROGRESS FOR THIS COMPLAINT; TO DATE NO ADDITIONAL INFORMATION OR PRODUCT HAS BEEN RECEIVED.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 1139125 | UNKNOWN SHELL | PROSTHESIS, HIP | LZO | BIOMET UK LTD. | UNKNOWN |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 | NA | Male | Required Intervention| H |