MAUDE Adverse Event Report: ENCORE MEDICAL L.P ALTIVATE REVERSE SHOULDER; ALTIVATE REVERSE,SMALL SOCKET INSERT,36MM SEMI CONSTRAINED+4

Model Number 508-03-436

Device Problem Appropriate Term/Code Not Available (3191)

Patient Problems Pain (1994); Numbness (2415)

Event Date 09/21/2020

Event Type  Injury  

Manufacturer Narrative

The reason for this revision surgery was reported as patient had to pain and numbness.The previous surgery and the surgery detailed in this event occurred 7 months apart.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 hospital and not made available to djo surgical for examination.A review of the device history record (dhr) shows that the reported component used in the previous surgery, when released for use, met design and manufacturing requirements.There were no non-conforming material reports (ncmr) associated with the product that may have contributed to the reported event.The device was verified to have gone through an acceptable sterilization process and was within its expiration date at the time of the previous surgery.Customer complaint history of the reported device showed no present trends or on-going issues that are needing a review.The root cause of this complaint was a revision surgery due to pain and numbness.There were no findings during this evaluation that indicate the reported device was defective.No information was submitted with the complaint regarding pre-existing conditions of the patient or any activities the patient was involved in that may have contributed to the event.There are multiple factors that may also contribute to an event that are outside the control of djo surgical such as poor bone density, patient bone deterioration, inadequate soft tissue support, patient activities or trauma.There are no indications of a product or process issue affecting implant safety or effectiveness.Additional reporting on this event will be provided as a supplemental report to this document if it becomes available.

Event Description

Revision surgery - the reverse shoulder was done with another djo vendor out in (b)(6).Patient had pain and numbness.Surgeon removed and replaced the 36mm small shell +4 semi constrained insert and replaced with a 36mm semi constrained insert.

• Brand Name: ALTIVATE REVERSE SHOULDER
• Type of Device: ALTIVATE REVERSE,SMALL SOCKET INSERT,36MM SEMI CONSTRAINED+4
• 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: 10784310
• MDR Text Key: 214522720
• Report Number: 1644408-2020-00965
• Device Sequence Number: 1
• Product Code: KWS
• UDI-Device Identifier: 00190446256977
• UDI-Public: (01)00190446256977
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K172351
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative
• Reporter Occupation: Physician
• Type of Report: Initial
• Report Date: 11/03/2020

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 11/04/2020
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Operator: Health Professional
• Device Expiration Date: 04/10/2023
• Device Model Number: 508-03-436
• Device Catalogue Number: 508-03-436
• Device Lot Number: 990W1005
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Date Manufacturer Received: 10/06/2020
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Date Device Manufactured: 04/26/2018
• 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: 78 YR