MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS INC US GLOBAL SHD END PEG GLEN 44; GLENOID (KEELED AND 5-PEGGED) IMPLANT : SHOULDER GLENOID

Model Number 1137-85-025

Device Problem Adverse Event Without Identified Device or Use Problem (2993)

Patient Problems Pain (1994); Appropriate Clinical Signs, Symptoms, Conditions Term / Code Not Available (4581)

Event Date 11/11/2020

Event Type  Injury  

Manufacturer Narrative

(b)(4).If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.

Event Description

Revision shoulder arthroplasty.Removal of global ap tsr, revising to competitor reverse shoulder arthroplasty.Additional information received via email from jnj sales representative: surgeon queried infection at implant site, as a reason for post op pain.

Event Description

Additional information received indicated that the affected side is left.Infection was not confirmed.

Manufacturer Narrative

Product complaint # (b)(4).This report is being submitted pursuant to the provisions of 21 cfr, part 803.This report may be based on information which has not been investigated or verified prior to the required reporting date.This report does not reflect a conclusion by depuy synthes joint reconstruction, or its employees that the report constitutes an admission that the product, depuy synthes joint reconstruction, or its employees caused or contributed to the potential event described in this report.H10 additional narrative: added: b5, g1.If information is obtained that was not available for the initial report, a follow-up report will be filed as appropriate.

Manufacturer Narrative

Product complaint # (b)(4).Investigation summary : no device associated with this report was received for examination.A worldwide complaint database search found no other related reported incidents against the provided product code/lot number combination since release for distribution.Based on previous investigations, this complication of joint replacement is unlikely to have been the result of a device failing to meet required specifications.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.Device history lot : no anomalies or deviations were found for the routed phases at the warsaw facility.

• Brand Name: GLOBAL SHD END PEG GLEN 44
• Type of Device: GLENOID (KEELED AND 5-PEGGED) IMPLANT : SHOULDER GLENOID
• Manufacturer (Section D): DEPUY ORTHOPAEDICS INC US; 700 orthopaedic drive; warsaw IN 46581 0988
• MDR Report Key: 10900824
• MDR Text Key: 218207219
• Report Number: 1818910-2020-25483
• Device Sequence Number: 1
• Product Code: KWT
• UDI-Device Identifier: 10603295007241
• UDI-Public: 10603295007241
• Combination Product (y/n): N
• PMA/PMN Number: K905786
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative,foreig
• Type of Report: Initial,Followup,Followup
• Report Date: 11/11/2020

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 11/25/2020
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Operator: Health Professional
• Device Model Number: 1137-85-025
• Device Catalogue Number: 113785025
• Device Lot Number: 110233
• Was Device Available for Evaluation?: No
• Date Manufacturer Received: 02/01/2021
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1
• Treatment: GLOBAL AP 135 DEG TAPER ASSEM.; GLOBAL AP HUMERAL HD 48X21 ECC.; GLOBAL AP HUMERAL STEM 10MM.; GLOBAL AP 135 DEG TAPER ASSEM.; GLOBAL AP HUMERAL HD 48X21 ECC.; GLOBAL AP HUMERAL STEM 10MM.
• Patient Outcome(s): Required Intervention
• Patient Age: 78 YR