MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS INC US GLOBAL AP 135 DEG TAPER ASSEM; GLOBAL AP IMPLANTS : SHOULDER HUMERAL STEM ACCESSORY

Model Number	1130-02-000
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Pain (1994); Appropriate Clinical Signs, Symptoms and Conditions Term/Code Not Available (4581)
Date of Event	11/11/2020
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 shoulder arthroplasty.Removal of global ap tsr, revising to competitor reverse shoulder arthroplasty.Additional information received via email from jnj sales representative: surgeon queried infection at implant site, as a reason for post op pain.
Additional Manufacturer Narrative
Product complaint # (b)(4).This report is being submitted pursuant to the provisions of 21 cfr, part 803.This report may be based on information which has not been investigated or verified prior to the required reporting date.This report does not reflect a conclusion by depuy synthes joint reconstruction, or its employees that the report constitutes an admission that the product, depuy synthes joint reconstruction, or its employees caused or contributed to the potential event described in this report.If information is obtained that was not available for the initial report, a follow-up report will be filed as appropriate.
Event or Problem Description
Additional information received indicated that the affected side is left.Infection was not confirmed.
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 related reported incidents against the provided product code/lot number combination 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.Device history lot : no anomalies or deviations were found for the routed phases at the warsaw facility.

• Brand Name: GLOBAL AP 135 DEG TAPER ASSEM
• Common Device Name: GLOBAL AP IMPLANTS : SHOULDER HUMERAL STEM ACCESSORY
• Manufacturer (Section D): DEPUY ORTHOPAEDICS INC US; 700 orthopaedic drive; warsaw IN 46581 0988
• MDR Report Key: 10900799
• Report Number: 1818910-2020-25482
• Device Sequence Number: 2489686
• Product Code: KWS
• UDI-Device Identifier: 10603295005438
• UDI-Public: 10603295005438
• Combination Product (Y/N): N
• Initial Reporter Country: AS
• PMA/510(K) Number: K060874
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Explanted Year: 2020
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 11/11/2020

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: 1130-02-000
• Device Catalogue Number: 113002000
• Device Lot Number: 161000
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 11/11/2020
• Supplement Date Received by Manufacturer: 11/11/2020; 02/01/2021
• Initial Report FDA Received Date: 11/25/2020
• Supplement Report FDA Received Date: 12/04/2020; 02/02/2021
• 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: GLOBAL AP HUMERAL HD 48X21 ECC.; GLOBAL AP HUMERAL STEM 10MM.; GLOBAL SHD END PEG GLEN 44.; GLOBAL AP HUMERAL HD 48X21 ECC.; GLOBAL AP HUMERAL STEM 10MM.; GLOBAL SHD END PEG GLEN 44.
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 78 YR