MAUDE MDR 8087218

MDR report key
8087218
Report number
2090010-2018-00005
Event key
0
Event type
3
Date of event
2018-08-01
Date received
2018-11-19
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
1
Health professional
3
Initial report to FDA
3
Event location
3

Manufacturer Contact#

Contact
MR. AARON
Address
5770 ARMADA DRIVE CARLSBAD CA 92008 US
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1SYNPLUG CEMENT RESTRICTORCEMENT OBTURATOR, PRODUCT CODE: LZNISOTIS ORTHOBIOLOGICS, INCLZNR N

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12018-11-1901. R

Event Narratives#

N

Patient 1

RADIOGRAPHS WERE PROVIDED FOR REVIEW IMAGES RECEIVED DID NOT DETECT OSTEOLYSIS AT THE PROXIMAL END OF THE PROSTHETIC SHAFT. A MEDICAL REVIEW OF THE RADIOGRAPH NOTES, WHAT IS NOTED AS OSTEOLYSIS IS MOST LIKELY RADIO RESIDUAL CEMENT PLUG. IF ANYTHING THE FEMORAL CORTICAL BIN LOOKS ALMOST NORMAL. LESS THAN NORMAL CEMENT DISTAL TO FEMORAL STEM. THE PLUG WOULD NOT PLAY A SIGNIFICANT ROLE IN THE FRACTURE. LOOKS LIKE THE FRACTURE OCCURRED PROXIMAL TO THE PLUG, AT THE END OF THE CEMENT MANTEL. ROOT CAUSE ANALYSIS: WITHIN IN MEDICAL PROBABILITY, AT 11 YEARS, THE SYNPLUG DID NOT CAUSE OR CONTRIBUTE TO THE FEMUR FRACTURE, LEFT. THOUGH THE 11 YEAR POST-OPERATIVE EVENT WAS ALLEGED TO INVOLVE SYNPLUG, TO DATE, THERE ARE NO CONCLUSIVE FINDINGS FROM THIS OR SIMILAR COMPLAINT INVESTIGATIONS, OR FROM TECHNICAL OR CLINICAL INFORMATION IN THE LITERATURE THAT PROVES OR DISPROVES A CAUSAL RELATIONSHIP BETWEEN SYNPLUG? & OPTIPLUG? BIODEGRADABLE CEMENT RESTRICTORS OR THE MATERIALS THEY ARE MANUFACTURED WITH, AND PERIPROSTHETIC OSTEOLYSIS (OR FRACTURES AS A RESULT). THERE ARE ALSO NO DATA OR FINDINGS THAT WOULD SUGGEST THAT ONLY SOME SUBSET OF ALL THE PRODUCTS MANUFACTURED MIGHT BE AFFECTED. A RISK/BENEFIT ANALYSIS OF TWO REPORTED FRACTURED, 58 REPORTED OSTEOLYSIS WITHOUT THE NEED FOR MEDICAL INTERVENTION AND 100,000+ PATIENTS BENEFITING FROM A SUCCESSFUL SURGERY IT CAN BE CONCLUDED THAT THE BENEFIT OUTWEIGHS THE RISK. THE FINDING OF OSTEOLYSIS SURROUNDING THE DISTAL CEMENT RESTRICTOR IS UNEXPECTED, AND UNDESIRABLE; HOWEVER, PERIPROSTHETIC OSTEOLYSIS IN TOTAL HIP ARTHROPLASTY IS A WELL-KNOWN PROBLEM THAT IS TYPICALLY A MULTIFACTORIAL PROCESS AND MAY BE IDENTIFIED THROUGH ROUTINE RADIOGRAPHIC FOLLOW-UP.

D

Patient 1

INITIAL HIP REPLACEMENT (HIP ARTHROPLASTY) SURGERY INVOLVING A HIP PROSTHESIS, WITH WEBER STRAIGHT SHAFT SS, FITMORE CUP SIZE 52, DURASUL INLAY SIZE 32, COBALT CHROME HEAD SIZE 32 MEDIUM, PALACOS CEMENT, SYNPLUG CEMENT RESTRICTOR SIZE 1, LEFT SIDE OCCURRED (B)(6) 2007. A FRACTURE ON LEFT SIDE REQUIRED SURGERY ON (B)(6) 2018. SURGERY CONSISTED OF OPEN, REPOSITION AND COMPOUND OSTEOSYNTHESIS OF LEFT FEMUR WITH PALACOS CEMENT AND NCB PLATE, LEFT FEMUR, ON (B)(6) 2018.