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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: FX SOLUTIONS HUMELOCK II; REVERSED SHOULDER PROSTHESIS
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FX SOLUTIONS HUMELOCK II; REVERSED SHOULDER PROSTHESIS Back to Search Results
Model Number DIAMETER 40+6
Health Effect - Clinical Code Joint Dislocation (2374)
Date of Event 06/07/2021
Type of Reportable Event Serious Injury
Additional Manufacturer Narrative
The event took place outside of the united states (in (b)(6)) and was associated with a product that is also cleared for the market within the united states.
 
Event or Problem Description
The event was a revision surgery due to dislocation that occured approximately 1 week after the primary surgery.The primary surgery used the humelock ii reversed system.During the revision surgery, the surgeon explanted the ø40/+6 135/145 humeral cup and replaced it by a ø40/+9 135/145 stability humeral cup.
 
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Brand Name
HUMELOCK II
Common Device Name
REVERSED SHOULDER PROSTHESIS
Manufacturer (Section D)
FX SOLUTIONS
1663 rue des majornas
viriat, 01440
FR  01440
MDR Report Key12257987
Report Number3009532798-2021-00106
Device Sequence Number19526124
Product Code PHX
UDI-Device Identifier03701037301517
UDI-Public03701037301517
Combination Product (Y/N)N
Initial Reporter CountryFR
PMA/510(K) Number
K150488
Number of Events Summarized1
Summary Report (Y/N)N
Device Implanted Year2021
Device Explanted Year2021
Serviced by Third Party (Y/N)N
Reporter Type Manufacturer
Report Source company representative
Initial Reporter Occupation Non-Healthcare Professional
Type of Report Initial
Report Date (Section B) 07/23/2021
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 Expiration Date04/01/2024
Device Model NumberDIAMETER 40+6
Device Catalogue Number314-0706
Device Lot NumberM2807
Was Device Available for Evaluation? No
Type of Report(Section G)Initial
Initial Date Received by Manufacturer 06/15/2021
Initial Report FDA Received Date08/02/2021
Is This a Single-Use Device that was
Reprocessed and Reused on a Patient? (Y/N)		 No
Patient Sequence Number1
Outcome Attributed to Adverse Event Hospitalization; Required Intervention;
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