BEUDAMED
    FDA Adverse Event Injury Summary report: N

    ELEVATED RIM LINER 36 MM I.D. SIZE JJ

    MDR report key: 8743851 · Received June 28, 2019

    Report

    Report Number
    0001822565-2019-02724
    Event Type
    Injury
    Date Received
    June 28, 2019
    Date of Event
    June 3, 2019
    Report Date
    September 5, 2019
    Manufacturer
    ZIMMER BIOMET, INC.
    Product Code
    JDI
    PMA / PMN Number
    K120370
    Removal / Correction Number
    N/A
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    AS
    Reporter Occupation
    PHYSICIAN

    Narratives

    Additional Manufacturer Narrative · 0

    UPON RECEIPT OF ADDITIONAL INFORMATION, IT HAS BEEN DETERMINED THAT THIS DEVICE DID NOT CAUSE OR CONTRIBUTE TO THE REPORTED EVENT. THE INITIAL REPORT WAS SUBMITTED IN ERROR AND SHOULD BE VOIDED.

    Description of Event or Problem · 0

    UPON RECEIPT OF ADDITIONAL INFORMATION IT HAS BEEN DETERMINED THAT THIS DEVICE DID NOT CAUSE OR CONTRIBUTE TO THE REPORTED EVENT. THE INITIAL REPORT WAS SUBMITTED IN ERROR AND SHOULD BE VOIDED.

    Additional Manufacturer Narrative · 1

    (B)(4). CONCOMITANT MEDICAL PRODUCTS: ZIMMER SHELL CAT#00875705401 LOT#63835532; ZIMMER HEAD CAT#00801803603 LOT#64020862; ZIMMER STEM CAT#0100351002 LOT#2945295; ZIMMER CENTRALIZER CAT#01.00358.010 LOT#2929718; ZIMMER ALLEN PLUG CAT#00801102024 LOT#63943174; REFOBACIN BONE CEMENT CAT#3020830401-3 LOT# A738AA0212. FOREIGN COUNTY: (B)(60. THE DEVICE WILL NOT BE RETURNED FOR ANALYSIS, DUE TO LOCATION OF DEVICE IS UNKNOWN; HOWEVER, AN INVESTIGATION OF THE REPORTED EVENT IS IN PROGRESS. ONCE THE INVESTIGATION HAS BEEN COMPLETED, A FOLLOW-UP MDR WILL BE SUBMITTED. MULTIPLE MDR REPORTS WERE FILED FOR THIS EVENT, PLEASE SEE ASSOCIATED REPORTS: 0001822565 - 2019 - 02725; 0002648920 - 2019 - 00482.

    Description of Event or Problem · 1

    IT WAS REPORTED PATIENT UNDERWENT HIP REVISION APPROXIMATELY 1 YEAR POST IMPLANTATION DUE TO MALALIGNMENT. IT WAS NOTED THAT ALL PRODUCT WAS REMOVED AND REPLACED. ATTEMPTS HAVE BEEN MADE AND ADDITIONAL INFORMATION ON THE REPORTED EVENT IS UNAVAILABLE AT THIS TIME.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    537739 ELEVATED RIM LINER 36 MM I.D. SIZE JJ PROSTHESIS, HIP JDI ZIMMER BIOMET, INC. N/A 63978781

    Patients

    Seq Age Sex Outcome Treatment
    1 Hospitalization| R