MAUDE Adverse Event Report: TORNIER INC TORNIER PERFORM REVERSED LATERALIZED BASEPLATE 3MM DIA 29MM; SHOULDER PROSTHESIS, REVERSE CONFIGURATION

Catalog Number	DWJ512
Medical Device Problem Codes	Unstable (1667); Device Dislodged or Dislocated (2923)
Health Effect - Clinical Codes	Subluxation (4525); Joint Laxity (4526)
Date of Event	08/27/2024
Type of Reportable Event	Serious Injury
Event or Problem Description
As reported: "study: shout subject: (b)(6).Post-operative ae: : instability ¿ dislocation.Subject lifted large water bottle on 8/7/24 and felt a pop.Imaging showed dislocated rsa.Patient required revision surgery.Re-operation with component change on (b)(6) 2024".
Additional Manufacturer Narrative
Based on the available information the device will not be returned therefore an evaluation of the device cannot be performed.Should additional information become available, it will be provided in a supplemental report.
Event or Problem Description
As reported: "study: shout subject: 002-00918.Post-operative ae: : instability ¿ dislocation.Subject lifted large water bottle on (b)(6) 2024 and felt a pop.Imaging showed dislocated rsa.Patient required revision surgery.Re-operation with component change on (b)(6) 2024".
Additional Manufacturer Narrative
After a complete review of the data provided by the complaint rep, the glenoid baseplate (catalog # dwj512) appears to have been retained (not explanted) in the patient.Therefore, mfr report # 0001649390-2024-00553 is no longer applicable and the record will canceled as this device has been deemed concomitant.

• Brand Name: TORNIER PERFORM REVERSED LATERALIZED BASEPLATE 3MM DIA 29MM
• Common Device Name: SHOULDER PROSTHESIS, REVERSE CONFIGURATION
• Manufacturer (Section D): TORNIER INC; 10801 nesbitt avenue s; bloomington MN 55437
• Manufacturer (Section G): TORNIER INC; 10801 nesbitt avenue s; bloomington MN 55437
• Manufacturer Contact: anna jusinski ; 325 corporate drive; mahwah, NJ 07430 ; 2018315000
• MDR Report Key: 20298704
• Report Number: 0001649390-2024-00553
• Device Sequence Number: 18359511
• Product Code: PHX
• UDI-Device Identifier: 00846832092079
• UDI-Public: 00846832092079
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K161742
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Health Professional
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 12/03/2024

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?: Yes
• Operator of Device: Lay User/Patient
• Device Catalogue Number: DWJ512
• Device Lot Number: 7668AT
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 08/27/2024
• Supplement Date Received by Manufacturer: 11/04/2024
• Initial Report FDA Received Date: 09/25/2024
• Supplement Report FDA Received Date: 12/03/2024
• Was Device Evaluated by Manufacturer? (Y/N): No
• 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: Required Intervention
• Patient Age: 77 YR
• Patient Sex: Male
• Patient Weight: 134 KG