MAUDE Adverse Event Report: AEQUALIS PERFORM GLENOID; SHOULDER JOINT POLYMER PROSTHESIS

Model Number	PEGGED SIZE S30
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Pain (1994); Joint Dislocation (2374)
Date of Event	04/21/2020
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
This is the initial report submitted regarding this surgical event and medical device.
Event or Problem Description
On (b)(6) 2018, the initial surgery of aequiles perform glenoid was performed.At this time, bone cysts were confirmed in the glenoid, but the operation was completed without any problems.During the periodic health examination on (b)(6) 2020, eversion at the affected part was confirmed.It had a little pain too.On (b)(6) 2020, surgery was completed by removing only the peg glenoid.The stem implant on the humeral side was not loosened, but the glenoid was slightly deformed.The surgeon commented that he wanted to know if the cause of eversion was due to instability of the peg glenoid due to lack of cement.
Additional Manufacturer Narrative
This is the final report submitted regarding this surgical event and medical device.The information contained in this report is being provided to the fda to comply with regulations regarding medical device reporting and is based on information submitted by others that may or may not be factually correct.This submission does not constitute a determination or admission that a device has malfunction or is related to a death or injury.

• Brand Name: AEQUALIS PERFORM GLENOID
• Common Device Name: SHOULDER JOINT POLYMER PROSTHESIS
• MDR Report Key: 10095464
• Report Number: 3000931034-2020-00066
• Device Sequence Number: 11598722
• Product Code: KWS
• UDI-Device Identifier: 03700386937330
• UDI-Public: 03700386937330
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: K111902
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2018
• Device Explanted Year: 2020
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 04/30/2020

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
• Operator of Device: No Information
• Device Expiration Date: 05/18/2023
• Device Model Number: PEGGED SIZE S30
• Device Catalogue Number: DWE301
• Device Lot Number: 7162AT
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 04/30/2020
• Supplement Date Received by Manufacturer: 04/30/2020
• Initial Report FDA Received Date: 05/28/2020
• Supplement Report FDA Received Date: 07/21/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Other
• Patient Age: 85 YR
• Patient Weight: 50