MAUDE Adverse Event Report: DEPUY FRANCE SAS - 3003895575 METAGLENE +10MM; DELTA XTEND IMPLANTS : SHOULDER METAGLENE

Model Number	1407-60-010
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Fall (1848); Pain (1994); No Code Available (3191)
Date of Event	06/24/2020
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
(b)(4).If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.
Event or Problem Description
Revision of delta xtend reverse shoulder replacement.Pt had a fall and was experiencing instability and pain.X-ray showed displacement of stem.All implants removed from pt, no implants placed back in.
Event or Problem Description
Additional information received.The affected side is left side.
Additional Manufacturer Narrative
Product complaint # (b)(4).Investigation summary : no device associated with this report was received for examination.A worldwide complaint database search found no other reported incident(s) against the provided product/lot combination(s) since release for distribution.Based on previous investigations this complication of joint replacement is unlikely to have been the result of a device failing to meet required specifications.The information received will be retained for potential series investigations if triggered by trend analysis, post market surveillance, or other events within the quality system.Corrective action was not indicated.

• Brand Name: METAGLENE +10MM
• Common Device Name: DELTA XTEND IMPLANTS : SHOULDER METAGLENE
• Manufacturer (Section D): DEPUY FRANCE SAS - 3003895575; 7 allee irene joliot-curie; b.p. 256; saint priest cedex 69801 ; FR 69801
• MDR Report Key: 10237680
• Report Number: 1818910-2020-15077
• Device Sequence Number: 2697298
• Product Code: HSD
• UDI-Device Identifier: 10603295272908
• UDI-Public: 10603295272908
• Combination Product (Y/N): N
• Initial Reporter Country: AS
• PMA/510(K) Number: K120174
• 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,foreig
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 06/24/2020

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: Health Professional
• Device Model Number: 1407-60-010
• Device Catalogue Number: 140760010
• Device Lot Number: 5304944
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 06/24/2020
• Supplement Date Received by Manufacturer: 09/15/2020
• Initial Report FDA Received Date: 07/06/2020
• Supplement Report FDA Received Date: 09/16/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: DXTEND GLENOSPHERE STD D38MM; DXTEND MBLOC HUM EPI 1 D8 STD; DXTEND RETENT PE CUP D38 +6MM; DXTEND SCREW LOCK D4.5X30MM; DXTEND SCREW LOCK D4.5X36MM; METAGLENE +10MM; UNKNOWN SHOULDER HUMERAL STEMS; DXTEND GLENOSPHERE STD D38MM; DXTEND MBLOC HUM EPI 1 D8 STD; DXTEND RETENT PE CUP D38 +6MM; DXTEND SCREW LOCK D4.5X30MM; DXTEND SCREW LOCK D4.5X36MM; METAGLENE +10MM; UNKNOWN SHOULDER HUMERAL STEMS
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 78 YR