MAUDE Adverse Event Report: FX SOLUTIONS HUMELOCK II ANATOMIC; METALLIC UNCEMENTED SHOULDER PROSTHESIS

Model Number 106-4316

Device Problem Output Problem (3005)

Patient Problem Appropriate Clinical Signs, Symptoms, Conditions Term / Code Not Available (4581)

Event Date 12/23/2021

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

Patient was revised on (b)(6) 2021 due to dismantling, approximately 3 weeks after the first surgery.The surgeon explanted centered head (43/16) and implanted centered head 43/16.

• Brand Name: HUMELOCK II ANATOMIC
• Type of Device: METALLIC UNCEMENTED SHOULDER PROSTHESIS
• Manufacturer (Section D): FX SOLUTIONS; 1663 rue des majornas; viriat, 01440 ; FR 01440
• Manufacturer (Section G): FX SOLUTIONS; 1663 rue des majornas; viriat, 01440 ; FR 01440
• Manufacturer Contact: ratsamy thevenin ; 1663 rue des majornas; viriat, 01440 ; FR 01440
• MDR Report Key: 13168711
• MDR Text Key: 283308841
• Report Number: 3009532798-2021-00260
• Device Sequence Number: 1
• Product Code: HSD
• UDI-Device Identifier: 03701037300404
• UDI-Public: 03701037300404
• Combination Product (y/n): N
• Reporter Country Code: FR
• PMA/PMN Number: K111097
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date: 01/03/2022

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 01/05/2022
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Model Number: 106-4316
• Device Catalogue Number: 106-4316
• Device Lot Number: N0363
• Was Device Available for Evaluation?: No
• Date Manufacturer Received: 12/23/2021
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• 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