MAUDE Adverse Event Report: DEPUY IRELAND - 3015516266 ANATOMIC OFFSET TAPER ADAPTER; SHOULDER IMPLANT - TAPER ADAPTER

Model Number 5120-00-110

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

Patient Problem Joint Laxity (4526)

Event Date 11/23/2022

Event Type  Injury  

Manufacturer Narrative

(b)(4).Depuy synthes is submitting this report pursuant to the provisions of 21 cfr, part 803.This report may be based on information which depuy synthes has not been able to investigate or verify prior to the required reporting date.This report does not reflect a conclusion by fda, depuy synthes or its employees that the report constitutes an admission that the device, depuy synthes, or its employees caused or contributed to the potential event described in this report.If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.No device associated with this report was received for examination.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.Depuy considers the investigation closed.Should additional information be received, the information will be reviewed and the investigation will be re-opened as necessary.

Event Description

Patient was revised due to stability issues that were not implant related.There was no surgical delay.Doi: (b)(6) 2022.Dor: (b)(6) 2022.Right shoulder.

• Brand Name: ANATOMIC OFFSET TAPER ADAPTER
• Type of Device: SHOULDER IMPLANT - TAPER ADAPTER
• Manufacturer (Section D): DEPUY IRELAND - 3015516266; loughbeg ringaskiddy co.; cork ; EI
• Manufacturer (Section G): DEPUY IRELAND - 9616671; loughbeg, ringaskiddy co; cork ; EI
• Manufacturer Contact: kate karberg ; 700 orthopaedic dr.; warsaw, IN 46581-0988 ; 3035526892
• MDR Report Key: 15952803
• MDR Text Key: 305233511
• Report Number: 1818910-2022-24988
• Device Sequence Number: 1
• Product Code: MBF
• UDI-Device Identifier: 10603295538189
• UDI-Public: 10603295538189
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K202716
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Health Professional,Company Representative
• Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date: 12/09/2022

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 12/09/2022
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Operator: Health Professional
• Device Model Number: 5120-00-110
• Device Catalogue Number: 512000110
• Device Lot Number: 172765
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Date Manufacturer Received: 11/23/2022
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Date Device Manufactured: 01/05/2022
• 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
• Treatment: ANATOMIC GLENOID S 24.; HUMERAL HEAD 40X15.75.; STEMLESS M 36.
• Patient Outcome(s): Required Intervention
• Patient Age: 55 YR
• Patient Sex: Female