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

Model Number	115-3610
Health Effect - Clinical Code	Joint Dislocation (2374)
Date of Event	01/27/2022
Type of Reportable Event	Serious Injury
Event or Problem Description
The patient was revised on (b)(6) 2022 following the initial surgery on (b)(6) 2021 due to disassociation as the humeral cup got disassociated from the stem.The surgeon explanted the centered glenosphere (36) and humeral cup (36/6).The surgeon implanted the centered glenosphere (40) and humeral cup (40/6).
Event or Problem Description
The patient was revised on (b)(6) 2022 following the initial surgery on (b)(6) 2021 due to disassociation as the humeral cup got disassociated from the stem.The surgeon explanted the centered glenosphere (36) and humeral cup (36/6).The surgeon implanted the centered glenosphere (40) and humeral cup (40/6).

• Brand Name: HUMERIS REVERSED
• Common Device Name: SHOULDER PROSTHESIS, REVERSE CONFIGURATION
• Manufacturer (Section D): FX SOLUTIONS; 1663 rue de majornas; viriat, 01440 ; FR 01440
• MDR Report Key: 13573081
• Report Number: 3014128390-2022-00005
• Device Sequence Number: 14967841
• Product Code: PHX
• UDI-Device Identifier: 03701037300800
• UDI-Public: 03701037300800
• 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: 2022
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Importer
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 02/21/2022
• Report Date (Section F): 02/21/2022

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: 05/02/2026
• Device Model Number: 115-3610
• Device Catalogue Number: 115-3610
• Device Lot Number: S0187
• Was the Report Sent to FDA?: Yes
• Distributor Facility Aware Date: 01/28/2022
• Event Location: Hospital
• Date Report to Manufacturer: 02/01/2022
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 02/21/2022
• 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: Hospitalization; Required Intervention
• Patient Age: 78 YR
• Patient Sex: Male
• Date Report Sent to FDA: 02/21/2022