MAUDE Adverse Event Report: ENCORE MEDICAL L.P. ALTIVATE SHOULDER; ENCORE REVERSE SHOULDER HUMERAL STEM, STD, SZ14X108MM

Model Number 530-14-108

Device Problem Device Dislodged or Dislocated (2923)

Patient Problem No Known Impact Or Consequence To Patient (2692)

Event Date 12/05/2017

Event Type  Injury  

Event Description

Revision surgery - due to the patient having dislocated at his 4 week follow up appointment.The surgeon revised him to make the shoulder stable.None of the implants had any problems.

Manufacturer Narrative

The reason for this revision surgery was due to a dislocation.The previous surgery and the revision detailed in this investigation occurred 28 days apart.There is no information in this complaint about any patient injuries, activities, or accidents that may have contributed to the need for this revision surgery.There are no reported pre-existing patient health conditions.The healthcare professional indicated there was no delay in surgery and another suitable device was available for use.The revision surgery was completed as intended.The device was disposed of at the hospital and not made available to djo surgical for examination.A review of the implant device history records (dhr) shows the non-conforming material report (ncmr) # (b)(4) associated with the part 530-14-108, altivate reverse humeral stem, standard, size 14, machined which documents a nonconformance that out of 15 quantity lot 2 items were rejected due to the presence of foreign material in porous coating and were accepted with a justification that downstream soda blast and acid clean operations will remove the foreign particle and part will be inspected 100% visually after each operations.All items in the lot met the fit, design and functional requirements.The device was within its expiration date at the time of use during the previous surgery.Customer complaint history of the reported device showed no present trends or on-going issues that are in need of review.The root cause of this complaint was a revision surgery due to the dislocation.There were no findings during this investigation that indicate that the reported device was the source or had a direct connection with the event.There are multiple factors that may contribute to the event that are outside the control of djo surgical such as: loose joint from inadequate soft tissue support, excessive range of motion, patient bone deterioration, patient activities or trauma.Due to the short duration between previous and revision surgery, it is also possible that the event may have occurred due to improper implant selection or patient noncompliance with medical instructions.Inventory containment is not required as there are no indications of a product or process issue affecting implant safety or effectiveness.

• Brand Name: ALTIVATE SHOULDER
• Type of Device: ENCORE REVERSE SHOULDER HUMERAL STEM, STD, SZ14X108MM
• Manufacturer (Section D): ENCORE MEDICAL L.P.; 9800 metric blvd; austin TX 78758 5445
• Manufacturer (Section G): ENCORE MEDICAL L.P.; 9800 metric blvd; austin TX 78758 5445
• Manufacturer Contact: teffany hutto ; 9800 metric blvd; austin, TX 78758-5445
• MDR Report Key: 7135407
• MDR Text Key: 95403765
• Report Number: 1644408-2017-01173
• Device Sequence Number: 1
• Product Code: PHX
• UDI-Device Identifier: 00888912168489
• UDI-Public: (01)00888912168489
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K141990
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative
• Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date: 02/05/2018

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?: No
• Device Operator: Health Professional
• Device Expiration Date: 07/03/2023
• Device Model Number: 530-14-108
• Device Catalogue Number: 530-14-108
• Device Lot Number: 415T1101
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Was the Report Sent to FDA?: No
• Initial Date Manufacturer Received: 12/05/2017
• Initial Date FDA Received: 12/20/2017
• Supplement Dates Manufacturer Received: 02/01/2018
• Supplement Dates FDA Received: 02/05/2018
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Date Device Manufactured: 07/11/2017
• 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: 508-32-101, LOT 862C2468; 509-01-032, LOT 381P1059
• Patient Outcome(s): Required Intervention
• Patient Age: 84 YR