MAUDE Adverse Event Report: ZIMMER BIOMET, INC. 25MM VERSA-DIAL TAPER ADAPTOR; COMPREHENSIVE SHOULDER SYSTEM MINI TAPER ADAPTOR

Catalog Number 118000

Device Problem Detachment of Device or Device Component (2907)

Patient Problem Joint Dislocation (2374)

Event Date 03/06/2024

Event Type  Injury  

Event Description

It was reported that the patient underwent an initial left shoulder arthroplasty approximately six (6) weeks ago.Subsequently, the patient was seen by their surgeon three (3) weeks later and it was discovered that the implants had disassociated.The patient underwent a revision surgery approximately three weeks ago.

Manufacturer Narrative

(b)(4).D10: medical products: item#: 110027734, compr vrs glen pps min tpr adr; lot#: 66573916.Item#: 110030776, cr 40mm glenosphere std cocr; lot#: 65398246.H3: product has been received by zimmer biomet and the investigation is in process.Once the investigation has been completed, a follow-up mdr will be submitted.

• Brand Name: 25MM VERSA-DIAL TAPER ADAPTOR
• Type of Device: COMPREHENSIVE SHOULDER SYSTEM MINI TAPER ADAPTOR
• Manufacturer (Section D): ZIMMER BIOMET, INC.; 56 e. bell drive; p.o. box 587; warsaw IN 46581
• Manufacturer (Section G): ZIMMER BIOMET, INC.; 56 e. bell drive; p.o. box 587; warsaw IN 46581
• Manufacturer Contact: jennifer rapsavage ; 56 e. bell dr.; warsaw, IN 46582 ; 5745260384
• MDR Report Key: 19132990
• MDR Text Key: 340474645
• Report Number: 0001825034-2024-01047
• Device Sequence Number: 1
• Product Code: PHX
• UDI-Device Identifier: 00880304531048
• UDI-Public: (01)00880304531048(17)331005(10)J7614800
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K193373
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Health Professional,Company Representative
• Reporter Occupation: Physician
• Type of Report: Initial
• Report Date: 04/16/2024

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Catalogue Number: 118000
• Device Lot Number: J7614800
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 04/09/2024
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Initial Date Manufacturer Received: 03/22/2024
• Initial Date FDA Received: 04/18/2024
• Was Device Evaluated by Manufacturer?: No
• Date Device Manufactured: 10/05/2023
• 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; Other