MAUDE Adverse Event Report: ENCORE MEDICAL L.P. ALTIVATE ANATOMIC, ALL-POLY PEGGED GLENOID, SIZE 38, E-PLUS; REVERSE PROSTHESIS SHOULDER SYSTEM

Catalog Number	521-07-238
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	11/16/2023
Type of Reportable Event	Serious Injury
Event or Problem Description
Revision surgery - mdr - wearing/required intervention to prevent impairment/damage (revision)-patient's glenoid had worn down, needed to be switched to reverse.
Additional Manufacturer Narrative
Complaint has been evaluated and is similar to previous report number 1644408-2021-01019; 521-07-254, s805 - wear/excessive wear, revision surgery.If additional information regarding the reported event is submitted at a future date, this investigation will be re-evaluated.

• Brand Name: ALTIVATE ANATOMIC, ALL-POLY PEGGED GLENOID, SIZE 38, E-PLUS
• Common Device Name: REVERSE PROSTHESIS SHOULDER SYSTEM
• Manufacturer (Section D): ENCORE MEDICAL L.P.; 9800 metric blvd; austin TX 78758 5445
• Manufacturer (Section G): ENCORE MEDICAL L.P.; 9800 metric blvd; austin TX 78758 5445
• Manufacturer Contact: james mcmahon ; 9800 metric blvd; austin, TX 78758-5445
• MDR Report Key: 18288866
• Report Number: 1644408-2023-01785
• Device Sequence Number: 5910440
• Product Code: PAO
• UDI-Device Identifier: 00190446178354
• UDI-Public: 00190446178354
• Combination Product (Y/N): N
• Initial Reporter State: FL
• Initial Reporter Country: US
• PMA/510(K) Number: K162024
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2017
• Device Explanted Year: 2023
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 12/07/2023

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 Expiration Date: 04/19/2022
• Device Catalogue Number: 521-07-238
• Device Lot Number: 890U1015
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 11/16/2023
• Initial Report FDA Received Date: 12/07/2023
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 05/02/2017
• 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: Unknown
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: 520-07-000 , LOT 888U1009; 520-08-000 , LOT 850U1008; 520-40-316 , LOT 876U1000
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 71 YR
• Patient Sex: Female