MAUDE Adverse Event Report: FX SOLUTIONS HUMELOCK II; SHOULDER PROTHESIS

Model Number 106-4300

Device Problem Material Split, Cut or Torn (4008)

Patient Problem No Code Available (3191)

Event Date 06/25/2020

Event Type  Injury  

Manufacturer Narrative

The event took place outside of the united states (in (b)(6)) and was associated with a product that is also cleared for the market within the united states.

Event Description

Revision surgery due to a cuff tear occurred (b)(6) 2020.The centered head and the double taper were removed and replaced by glenoid baseplate, ø40 glenosphere and ø40+3 humeral cup.Primary surgery on (b)(6) 2018.

• Brand Name: HUMELOCK II
• Type of Device: SHOULDER PROTHESIS
• Manufacturer (Section D): FX SOLUTIONS; 1663 rue de majornas; viriat, 01440 ; FR 01440
• Manufacturer (Section G): FX SOLUTIONS; 1663 rue de majornas; viriat, 01440 ; FR 01440
• Manufacturer Contact: cédric joly ; 1663 rue de majornas; viriat, 01440 ; FR 01440
• MDR Report Key: 10245534
• MDR Text Key: 198018309
• Report Number: 3009532798-2020-00277
• Device Sequence Number: 1
• Product Code: HSD
• Combination Product (y/n): N
• Reporter Country Code: FR
• PMA/PMN Number: K130759
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative
• Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date: 07/08/2020

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 07/08/2020
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Operator: Health Professional
• Device Expiration Date: 01/01/2023
• Device Model Number: 106-4300
• Device Lot Number: L1743
• Was Device Available for Evaluation?: No
• Date Manufacturer Received: 07/02/2020
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Date Device Manufactured: 01/30/2018
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1
• Patient Outcome(s): Hospitalization; Required Intervention
• Patient Age: 77 YR