MAUDE Adverse Event Report: TORNIER S.A.S. AEQ REV II GLENOID SPHERE DIA 39 X 25 TILTED BASEPLATE; PROSTHESIS, SHOULDER, SEMI-CONSTRAINED, METAL/POLYMER CEMENTED

Model Number	DWH905
Medical Device Problem Codes	Unstable (1667); Device Dislodged or Dislocated (2923)
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	04/04/2022
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Based on the available information the device will not be returned therefore an evaluation of the device cannot be performed.Should additional information become available, it will be provided on a supplemental report.
Event or Problem Description
It was reported that the patient underwent reverse shoulder replacement on (b)(6) 2021.Recently, the patient experienced instability of this prosthetic joint.Surgeon examined shoulder / manipulation under anesthetic - demonstrated instability.Radiographically, the prosthesis appeared well positioned.The physician then opened the shoulder - surgeon removed poly (6mm reversed insert, dwf391c), 0mm reversed tray (dwf510) and 39mm lat glenosphere (dwh905).Implanted a 42mm glenosphere, +6mm reversed tray and an insert.
Event or Problem Description
It was reported that the patient underwent reverse shoulder replacement on (b)(3) 2021.Recently, the patient experienced instability of this prosthetic joint.Surgeon examined shoulder / manipulation under anesthetic - demonstrated instability.Radiographically, the prosthesis appeared well positioned.The physician then opened the shoulder - surgeon removed poly (6mm reversed insert, dwf391c), 0mm reversed tray (dwf510) and 39mm lat glenosphere (dwh905).Implanted a 42mm glenosphere, +6mm reversed tray and an insert.
Additional Manufacturer Narrative
The reported event could not be confirmed since the device was not returned for evaluation.More detailed information about the complaint event as well as the affected device must be available in order to determine the root cause of the complaint event.A review of the device history for the reported lot did not indicate any abnormalities.No corrective actions are required at this time.A review of the labeling did not indicate any abnormalities.No indications of material, manufacturing or design related problems were found during the investigation.If the device is returned or if any additional information is provided, the investigation will be reassessed.

• Brand Name: AEQ REV II GLENOID SPHERE DIA 39 X 25 TILTED BASEPLATE
• Common Device Name: PROSTHESIS, SHOULDER, SEMI-CONSTRAINED, METAL/POLYMER CEMENTED
• Manufacturer (Section D): TORNIER S.A.S.; 161 rue lavoisier; montbonnot saint-martin 38330 ; FR 38330
• Manufacturer (Section G): TORNIER S.A.S.; 161 rue lavoisier; montbonnot saint-martin 38330 ; FR 38330
• Manufacturer Contact: anna jusinski ; 325 corporate drive; mahwah, NJ 07430 ; 2018315000
• MDR Report Key: 14270259
• Report Number: 3000931034-2022-00216
• Device Sequence Number: 5702962
• Product Code: KWS
• UDI-Device Identifier: 03700386955099
• UDI-Public: 03700386955099
• Combination Product (Y/N): N
• Initial Reporter Country: AS
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2021
• Device Explanted Year: 2022
• Reporter Type: Manufacturer
• Report Source: Distributor
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 07/11/2022

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?: Yes
• Operator of Device: Lay User/Patient
• Device Expiration Date: 09/04/2025
• Device Model Number: DWH905
• Device Catalogue Number: DWH905
• Device Lot Number: 9398AV
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Follow-Up
• Initial Date Received by Manufacturer: 04/04/2022
• Supplement Date Received by Manufacturer: 06/14/2022
• Initial Report FDA Received Date: 05/03/2022
• Supplement Report FDA Received Date: 07/11/2022
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 09/04/2020
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 60 YR
• Patient Sex: Female