MAUDE Adverse Event Report: ENCORE MEDICAL L.P SOCKET, INSERT 32MM SEMI RSP HUMERAL; SHOULDER PROSTHESIS, REVERSE CONFIGURATION

Catalog Number	508-01-032
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Unspecified Infection (1930)
Date of Event	02/15/2024
Type of Reportable Event	Serious Injury
Event or Problem Description
Revision surgery - due to infection.
Additional Manufacturer Narrative
Complaint has been evaluated and is similar to previous report number 1644408-2023-00505; 3508-01-032, s808 - infection, revision surgery.If additional information regarding the reported event is submitted at a future date, this investigation will be re-evaluated.

• Brand Name: SOCKET, INSERT 32MM SEMI RSP HUMERAL
• Common Device Name: SHOULDER PROSTHESIS, REVERSE CONFIGURATION
• Manufacturer (Section D): ENCORE MEDICAL L.P; 9800 metric blvd; austin TX 78758
• Manufacturer (Section G): ENCORE MEDICAL L.P; 9800 metric blvd; austin TX 78758
• Manufacturer Contact: james mcmahon ; 9800 metric blvd; austin, TX 78758
• MDR Report Key: 18874142
• Report Number: 1644408-2024-00309
• Device Sequence Number: 7887445
• Product Code: PHX
• UDI-Device Identifier: 00888912024693
• UDI-Public: 00888912024693
• Combination Product (Y/N): N
• Initial Reporter State: IN
• Initial Reporter Country: US
• PMA/510(K) Number: K051075
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2019
• Device Explanted Year: 2024
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 03/09/2024

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: 05/09/2023
• Device Catalogue Number: 508-01-032
• Device Lot Number: 859C1133
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 02/15/2024
• Initial Report FDA Received Date: 03/11/2024
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 05/23/2018
• 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: 506-03-126 LOT: 834C1538; 506-03-126 LOT: 834C1564; 506-03-130 LOT: 835C1525; 506-03-134 LOT: 836C1257; 508-32-101 LOT: 862C2842; 508-32-104 LOT: 866C2562; 530-14-108 LOT: 415T1218
• Outcome Attributed to Adverse Event: Other
• Patient Age: 77 YR
• Patient Sex: Male