BEUDAMED
    FDA Adverse Event Injury Summary report: N

    S-ROM SLEEVE PRX ZTT, 16B-LRG

    MDR report key: 1983571 · Received January 31, 2011

    Report

    Report Number
    1818910-2011-01539
    Event Type
    Injury
    Date Received
    January 31, 2011
    Date of Event
    January 5, 2011
    Report Date
    January 5, 2011
    Manufacturer
    DEPUY-CORK, A DIVISION OF DEPUY ORTHOPAEDICS
    Product Code
    MRA
    PMA / PMN Number
    P040023
    Removal / Correction Number
    NA
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    OH, US
    Reporter Occupation
    OTHER

    Narratives

    Additional Manufacturer Narrative · 1

    THIS COMPLAINT IS STILL UNDER INVESTIGATION. DEPUY WILL NOTIFY THE FDA OF THE RESULTS OF THIS INVESTIGATION ONCE IT HAS BEEN COMPLETED.

    Description of Event or Problem · 1

    PT WAS REVISED TO ADDRESS STEM LOOSENING. SLEEVE NEVER GREW IN.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 S-ROM SLEEVE PRX ZTT, 16B-LRG 87MRA MRA DEPUY-CORK, A DIVISION OF DEPUY ORTHOPAEDICS NA 2407900

    Patients

    Seq Age Sex Outcome Treatment
    1 65 YR Required Intervention