MAUDE Adverse Event Report: ARTHREX, INC. 24MM +4 LAT BASEPLATE, MODULAR; SHOULDR PROSTH, REVERSE CONFIG

Model Number	24MM +4 LAT BASEPLATE, MODULAR
Medical Device Problem Code	Detachment of Device or Device Component (2907)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	04/27/2023
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
This 3500a record is submitted to comply with an fda 483 inspectional observation issued to arthrex inc on may 5, 2023.Arthrex has reassessed the reportability decisions made on historical complaint records using revised criterion.This 3500a document is a result of the reassessment.Since the complaint device was not returned, a physical evaluation of the device was not performed.However, the complaint allegation is not confirmed without the device being returned or any photos provided.The most likely cause for the reported failure can be attributed to the misaligned insertion of the device with the matting part.
Event or Problem Description
On 4/27/2023, it was reported by a sales representative via email that an ar-9560-24-4 modulas baseplate became disengaged from an ar-9561-35s central screw when the first ar-9563-36 peripheral screw was inserter.The head of the ar-9563-36 peripheral screw was stripped.The surgeon removed everything from inside the patient and opened a new ar-9560-24-4 modulas baseplate, an ar-9561-35s central screw, and an ar-9563-36 peripheral screw to complete the case.The surgeon ensured the central screw was well seated on the baseplate while on the back table before implanting the new products.This was discovered during a procedure on (b)(6) 2023.Additional information received on 5/1/2023: this was discovered during an rts and completed with another ar-9560-24-4 modulas baseplate, ar-9561-35s central screw, and ar-9563-36 peripheral screw.

• Brand Name: 24MM +4 LAT BASEPLATE, MODULAR
• Common Device Name: SHOULDR PROSTH, REVERSE CONFIG
• Manufacturer (Section D): ARTHREX, INC.; 1370 creekside boulevard; naples FL 34108 1945
• Manufacturer (Section G): ARTHREX, INC.; 1370 creekside boulevard; naples FL 34108 1945
• Manufacturer Contact: jared engle ; 8009337001
• MDR Report Key: 19510183
• Report Number: 1220246-2024-05551
• Device Sequence Number: 19721395
• Product Code: PHX
• UDI-Device Identifier: 00888867296473
• UDI-Public: 00888867296473
• Combination Product (Y/N): N
• Initial Reporter State: WI
• Initial Reporter Country: US
• PMA/510(K) Number: K173900
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Distributor
• Initial Reporter Occupation: Administrator/Supervisor
• Type of Report: Initial
• Report Date (Section B): 06/11/2024

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Model Number: 24MM +4 LAT BASEPLATE, MODULAR
• Device Catalogue Number: AR-9560-24-4
• Device Lot Number: 14947842
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 04/27/2023
• Initial Report FDA Received Date: 06/11/2024
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 04/06/2022
• 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
• Patient Sex: Unknown