MAUDE Adverse Event Report: EXACTECH, INC. HUMERAL LINER, 40MM, +0; SHOULDER PROSTHESIS, REVERSE CONFIGURATION

Catalog Number	320-40-00
Medical Device Problem Codes	Unstable (1667); Device Dislodged or Dislocated (2923)
Health Effect - Clinical Codes	Joint Dislocation (2374); Subluxation (4525); Joint Laxity (4526)
Date of Event	03/01/2020
Type of Reportable Event	Serious Injury
Event or Problem Description
As reported by the equinoxe shoulder study, the patient, (b)(6), had an initial left tsa on (b)(6) 2019.Patient (b)(6) presented on 01-mar-2020 with instability / subluxation.Patient describes 2 subluxation episodes at home; both "self-reduced." the case report form indicates that this event is possibly related to device and/or to procedure.Outcome is resolved on 01-apr-2021 with deltoid strengthening exercises.Due to clinical study, no devices will be returned for evaluation.
Additional Manufacturer Narrative
(h3) pending evaluation (d10) concomitant device(s): 320-31-40 - glenosphere, 40mm: (b)(6).300-01-14 - equinoxe humeral stem primary press fit 14mm: (b)(6).320-10-00 - equinoxe reverse tray adapter plate tray +0:(b)(6).320-35-01 - small glenoid plate: (b)(6).
Additional Manufacturer Narrative
This follow-up report is being submitted to relay additional and/or corrected information.The following sections were updated/corrected: h6.Mdr section codes updated/corrected: a, b, c, d, e, f, g.The cause of the patient¿s shoulder dislocation and subsequent revision reported cannot be conclusively determined; however, it may be due to soft tissue imbalance, patient anatomy, implant positioning, and/or implant selection.Dislocation is a known risk, as outlined in the ifu.If any further information is obtained that would change or alter any information provided, a supplemental report will be filed accordingly.

• Brand Name: HUMERAL LINER, 40MM, +0
• Common Device Name: SHOULDER PROSTHESIS, REVERSE CONFIGURATION
• Manufacturer (Section D): EXACTECH, INC.; 2320 nw 66 court; gainesville FL 32653
• Manufacturer (Section G): EXACTECH; 2320 nw 66th ct.; gainesville FL 32653
• Manufacturer Contact: miguel sosa ; 2320 nw 66th ct.; gainesville, FL 32653 ; 3523771140
• MDR Report Key: 18358902
• Report Number: 1038671-2023-03030
• Device Sequence Number: 7743399
• Product Code: PHX
• UDI-Device Identifier: 10885862535030
• UDI-Public: 10885862535030
• Combination Product (Y/N): N
• Initial Reporter State: CO
• Initial Reporter Country: US
• PMA/510(K) Number: K180632
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2019
• Reporter Type: Manufacturer
• Report Source: Study,Company Representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 07/09/2025

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: 01/14/2024
• Device Catalogue Number: 320-40-00
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 11/18/2023
• Supplement Date Received by Manufacturer: 07/08/2025
• Initial Report FDA Received Date: 12/19/2023
• Supplement Report FDA Received Date: 07/09/2025
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 01/16/2019
• 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
• Concomitant Medical Products and Therapy/Usage Dates: SEE H10
• Patient Age: 63 YR
• Patient Sex: Male
• Patient Weight: 88 KG
• Patient Race: White