MAUDE Adverse Event Report: FX SOLUTIONS HUMELOCK REVERSED; SHOULDER PROSTHESIS, REVERSE CONFIGURATION

Model Number	103-1003
Health Effect - Clinical Code	Insufficient Information (4580)
Date of Event	12/20/2021
Type of Reportable Event	Serious Injury
Event or Problem Description
The patient was revised on (b)(6) 2021, approximately 11 months after the primary surgery on (b)(6) 2021.The revision was due to dislocation.The surgeon explanted the standard humeral cup (36/+3) and implanted a stability humeral cup (36/+6).

• Brand Name: HUMELOCK REVERSED
• Common Device Name: SHOULDER PROSTHESIS, REVERSE CONFIGURATION
• Manufacturer (Section D): FX SOLUTIONS; 1663 rue de majornas; viriat, 01440 ; FR 01440
• MDR Report Key: 13158557
• Report Number: 3014128390-2021-00074
• Device Sequence Number: 5478982
• Product Code: PHX
• UDI-Device Identifier: 03701037309414
• UDI-Public: 03701037309414
• Combination Product (Y/N): N
• Initial Reporter State: TX
• Initial Reporter Country: US
• 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: Importer
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 01/04/2022
• Report Date (Section F): 01/04/2022

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: 05/01/2025
• Device Model Number: 103-1003
• Device Catalogue Number: 103-1003
• Device Lot Number: N3269
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: Yes
• Distributor Facility Aware Date: 12/20/2021
• Event Location: Hospital
• Date Report to Manufacturer: 12/21/2021
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 01/04/2022
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention; Hospitalization
• Patient Age: 80 YR
• Patient Sex: Female
• Date Report Sent to FDA: 01/04/2022