MAUDE Adverse Event Report: ARTHREX, INC. UNIVERS REVS STEM SZ 9,REV.,CTD; PROSTHESIS, SHOULDER, SEMI-CONSTRAINED, METAL/POLYMER CEMENTED

Model Number	UNIVERS REVS STEM SZ 9,REV.,CTD
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	03/16/2021
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The contribution of the device to the reported event could not be determined as the device was not returned for evaluation.The root cause of the event could not be determined from the information available and without device evaluation.
Event or Problem Description
It was reported that a revision was necessary after a distal protrusion of the long humeral shaft.The patient will be rehabilitated at a later date after a humeral bone grafting procedure.The base plate including screws have remained in the patient.No further information were provided.
Additional Manufacturer Narrative
Complaint confirmed, the x-ray provided shows the bone-protrusion.The ar-9501-09rcpc device was not returned for evaluation and the picture provided did not show any abnormality.The cause of the event is undetermined.

• Brand Name: UNIVERS REVS STEM SZ 9,REV.,CTD
• Common Device Name: PROSTHESIS, SHOULDER, SEMI-CONSTRAINED, METAL/POLYMER CEMENTED
• Manufacturer (Section D): ARTHREX, INC.; 1370 creekside boulevard; naples FL 34108 1945
• MDR Report Key: 11630582
• Report Number: 1220246-2021-02855
• Device Sequence Number: 19829574
• Product Code: KWS
• UDI-Device Identifier: 00888867061040
• UDI-Public: 00888867061040
• Combination Product (Y/N): N
• Initial Reporter Country: SZ
• PMA/510(K) Number: K130129
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: foreign,health professional,u
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 05/13/2021

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: UNIVERS REVS STEM SZ 9,REV.,CTD
• Device Catalogue Number: AR-9501-09RCPC
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 03/18/2021
• Supplement Date Received by Manufacturer: 03/18/2021
• Initial Report FDA Received Date: 04/07/2021
• Supplement Report FDA Received Date: 05/13/2021
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Other