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
Health Effect - Clinical Code	Unspecified Infection (1930)
Date of Event	09/14/2021
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Additional reporting on this event will be provided as a supplemental report to this document as soon as it becomes available.
Event or Problem Description
Revision surgery - the patient was infected, the surgeon removed all of the hardware in the patient.He used our stem, hemi adapter, and anatomic head to create a spacer.He wrapped the spacer with antibiotic infused cement and placed it in the patient.
Additional Manufacturer Narrative
The reason for this revision surgery was reported as an infection.The previous surgery and the surgery detailed in this event occurred 2 months and 1 week 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 devices were disposed of at hospital and not made available to djo surgical for examination.A review of the device history records (dhr) show that the reported components used in the previous surgery, when released for use, met design and manufacturing requirements and showed no non-conforming material reports (ncmr) associated with the main contributor component listed in the complaint.The devices were verified to have gone through an acceptable sterilization process and were within its expiration date at the time of the previous surgery.Customer complaint history of the reported devices 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 an infection.There were no findings during this evaluation that indicate the reported devices were the source or had a direct connection with the patient's infection.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 possible infection or inhibited the patient's immune system.There are multiple factors that may contribute to an infection that are outside the control of djo surgical.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.

• Brand Name: ALTIVATE REVERSE SHOULDER
• Common Device Name: ALTIVATE REVERSE,SMALL SOCKET INSERT,36MM SEMI CONSTRAINED+4
• Manufacturer (Section D): ENCORE MEDICAL L.P.; 9800 metric blvd; austin, tx 78758-5445
• MDR Report Key: 12519960
• Report Number: 1644408-2021-01034
• Device Sequence Number: 5159677
• Product Code: KWS
• UDI-Device Identifier: 00190446256977
• UDI-Public: (01)00190446256977
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K172351
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2021
• Device Explanted Year: 2021
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 09/30/2021

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 Date: 04/12/2023
• Device Model Number: 508-03-436
• Device Catalogue Number: 508-03-436
• Device Lot Number: 990W1006
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 09/14/2021
• Supplement Date Received by Manufacturer: 09/29/2021
• Initial Report FDA Received Date: 09/23/2021
• Supplement Report FDA Received Date: 09/30/2021
• 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: 506-03-118 LOT 832C1767; 506-03-118 LOT 832C1774; 506-03-118 LOT 832C1788; 506-03-118 LOT 832C1793; 508-32-204 LOT 769P2005; 508-36-101 LOT 869C2584; 533-10-175 LOT 930W1008; 533-12-000 LOT 005Y1024; 506-03-118 LOT 832C1767; 506-03-118 LOT 832C1774; 506-03-118 LOT 832C1788; 506-03-118 LOT 832C1793; 508-32-204 LOT 769P2005; 508-36-101 LOT 869C2584; 533-10-175 LOT 930W1008; 533-12-000 LOT 005Y1024
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 72 YR