MAUDE Adverse Event Report: ARTHREX, INC. 5.5X20MM PERIPHERAL SCREW, LOCKING; SHOULDER PROSTHESIS, REVERSE CONFIGURATION

Model Number	5.5X20MM PERIPHERAL SCREW, LOCKING
Health Effect - Clinical Code	Insufficient Information (4580)
Date of Event	04/30/2021
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.If the device becomes available for evaluation, a follow-up report will be submitted.
Event or Problem Description
It was reported that a reverse total shoulder revision surgery was performed on (b)(6) 2021.The primary procedure took place on (b)(6) 2020.See attached pre-operative x-rays images.The following arthrex product was explanted during the revision surgery; ar-9502f-36cpc (lot: 19.02550), ar-9503-3633-3 (lot: 19.00009), ar-9560-24-2 (lot: 6364), ar-9561-20s (lot: 7039), ar-9562-36nl (lot: 18.01681 / this screw was broken), ar-9563-20 (lot: 19.00617), ar-9563-24 (lot: 2018005452), ar-9564-2433-lat (lot: 19.00014).The following arthrex product was implanted during the revision surgery; ar-9502f-36cpc (lot: 19.04723), ar-9503s-03c (lot: 19.00504).

• Brand Name: 5.5X20MM PERIPHERAL SCREW, LOCKING
• Common Device Name: SHOULDER PROSTHESIS, REVERSE CONFIGURATION
• Manufacturer (Section D): ARTHREX, INC.; 1370 creekside boulevard; naples FL 34108 1945
• MDR Report Key: 11872374
• Report Number: 1220246-2021-03157
• Device Sequence Number: 10974651
• Product Code: PHX
• UDI-Device Identifier: 00888867296824
• UDI-Public: 00888867296824
• Combination Product (Y/N): N
• Initial Reporter State: MO
• Initial Reporter Country: US
• PMA/510(K) Number: K173900
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2020
• Device Explanted Year: 2021
• Reporter Type: Manufacturer
• Report Source: distributor
• Initial Reporter Occupation: Administrator/Supervisor
• Type of Report: Initial
• Report Date (Section B): 05/24/2021

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: 5.5X20MM PERIPHERAL SCREW, LOCKING
• Device Catalogue Number: AR-9563-20
• Device Lot Number: 19.00617
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 05/03/2021
• Initial Report FDA Received Date: 05/24/2021
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Other