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

Model Number 103-0803

Device Problem Unstable (1667)

Patient Problem Damage to Ligament(s) (1952)

Event Date 05/23/2023

Event Type  Injury  

Manufacturer Narrative

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

Event Description

The patient was revised due to instability on (b)(6)2023.The implantation date was on (b)(6)2023.A cup was explanted.A cup was implanted.

• Brand Name: HUMELOCK REVERSED
• Type of Device: REVERSED SHOULDER PROTHESIS
• 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: 17016449
• MDR Text Key: 316118928
• Report Number: 3009532798-2023-00041
• Device Sequence Number: 1
• Product Code: PHX
• UDI-Device Identifier: 03701037300091
• UDI-Public: 03701037300091
• Combination Product (y/n): N
• Reporter Country Code: FR
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date: 05/25/2023

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 05/29/2023
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Operator: Health Professional
• Device Model Number: 103-0803
• Device Catalogue Number: 103-0803
• Device Lot Number: T1422
• Was Device Available for Evaluation?: No
• Date Manufacturer Received: 05/23/2023
• 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