MAUDE Adverse Event Report: FX SOLUTIONS HUMELOCK 2; REVERSED SHOULDER PROTHESIS

Model Number	103-0806
Medical Device Problem Code	Unstable (1667)
Health Effect - Clinical Code	Subluxation (4525)
Date of Event	01/31/2023
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
This mdr has already been submitter to fda by the us importer with report number 3014128390-2023-00008.
Event or Problem Description
The patient was revised due to dislocation on (b)(6) 2023.The implantation date was on (b)(6) 2022.A cup, a glenosphere, a humeral spacer and a cementeless glenoid were explanted.A cup, a glenosphere, a humeral spacer and a cementeless glenoid were implanted.

• Brand Name: HUMELOCK 2
• Common Device Name: REVERSED SHOULDER PROTHESIS
• Manufacturer (Section D): FX SOLUTIONS; 1663 rue des majornas; viriat, 01440 ; FR 01440
• Manufacturer (Section G): FX SOLUTIONS; 1663 rue des majornas; viriat, 01440 ; FR 01440
• Manufacturer Contact: ratsamy thevenin ; 1663 rue des majornas; viriat, 01440 ; FR 01440
• MDR Report Key: 16731648
• Report Number: 3009532798-2023-00022
• Device Sequence Number: 6674066
• Product Code: PHX
• UDI-Device Identifier: 03701037300107
• UDI-Public: 03701037300107
• Combination Product (Y/N): N
• Initial Reporter Country: FR
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2022
• Device Explanted Year: 2023
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 04/03/2023

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 Model Number: 103-0806
• Device Catalogue Number: 103-0806
• Device Lot Number: S1038
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 02/27/2023
• Initial Report FDA Received Date: 04/13/2023
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• 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: Hospitalization
• Patient Sex: Unknown