MAUDE Adverse Event Report: ACUMED LLC ARH SLIDE-LOC HEAD 22MM, RIGHT; PROSTHESIS, ELBOW, HEMI-, RADIAL, HEAD

Model Number 5001-0222R-S

Device Problem Detachment Of Device Component (1104)

Patient Problem No Code Available (3191)

Event Type  Injury  

Manufacturer Narrative

The head and neck were assembled.The laser lines were aligned properly.There were marks on the engagement surface of the neck, suggesting the neck did engage with the stem.Additional mdrs associated with this event: 3025141-2017-00305: neck.3025141-2017-00306: stem.

Event Description

An arh slide-loc radial head implant was implanted on (b)(6) 2015.At some point post operatively, the head/neck assembly dissociated.The implant was replaced with new arh slide-loc components on (b)(6) 2017.

• Brand Name: ARH SLIDE-LOC HEAD 22MM, RIGHT
• Type of Device: PROSTHESIS, ELBOW, HEMI-, RADIAL, HEAD
• Manufacturer (Section D): ACUMED LLC; 5885 nw cornelius pass road; hillsboro OR 97124
• Manufacturer (Section G): ACUMED LLC; 5885 nw cornelius pass road; hillsboro OR 97124
• Manufacturer Contact: micki lehman ; 5885 nw cornelius pass road; hillsboro, OR 97124 ; 8886279957
• MDR Report Key: 7075690
• MDR Text Key: 93492253
• Report Number: 3025141-2017-00304
• Device Sequence Number: 1
• Product Code: KWI
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K131845
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: distributor
• Reporter Occupation: Other
• Type of Report: Initial
• Report Date: 11/08/2017

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 12/01/2017
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Operator: Physician
• Device Expiration Date: 02/28/2022
• Device Model Number: 5001-0222R-S
• Device Catalogue Number: 5001-0222R-S
• Device Lot Number: 340993
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 11/15/2017
• Is the Reporter a Health Professional?: No
• Was the Report Sent to FDA?: No
• Date Manufacturer Received: 11/08/2017
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 03/05/2015
• 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): Required Intervention
• Patient Age: 37 YR
• Patient Weight: 55