MAUDE Adverse Event Report: FX SHOULDER SOLUTIONS DALLAS HUMELOCK REVERSED; REVERSE SHOULDER PROSTHESIS

Catalog Number	105-0230
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Joint Laxity (4526)
Date of Event	09/19/2024
Type of Reportable Event	Serious Injury
Event or Problem Description
Revision occurred approximately 10 months after the primary surgery which occurred on (b)(6) 2023.No fall or other trauma reported.Revision occurred due to failure of the glenoid implant and was a dual system implantation.15 degree + 6 lateralized glenoid baseplate, 36 mm centered glenosphere, 36 mm + 3 standard humeral, and 5 screws explanted.These parts were replaced with a 36 mm + 6 standard humeral cup and a competitor assembly for the glenoid side.
Additional Manufacturer Narrative
Revision occurred after 10 months due to failure of the glenoid.No actual, implied, or suspect link to fx product.

• Brand Name: HUMELOCK REVERSED
• Common Device Name: REVERSE SHOULDER PROSTHESIS
• Manufacturer (Section D): FX SHOULDER SOLUTIONS DALLAS; 15920 addison road; addison TX
• Manufacturer (Section G): FX SHOULDER SOLUTIONS DALLAS; 15920 addison road; addison TX 75001
• Manufacturer Contact: tristan mahler ; 15920 addison road; addison, TX 75001 ; 7137326920
• MDR Report Key: 20417275
• Report Number: 3014128390-2024-00051
• Device Sequence Number: 15527791
• Product Code: PHX
• UDI-Device Identifier: 03701037316863
• UDI-Public: 03701037316863
• Combination Product (Y/N): N
• Initial Reporter State: OH
• Initial Reporter Country: US
• PMA/510(K) Number: K210790
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2023
• Device Explanted Year: 2024
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Distributor
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 10/10/2024

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 Catalogue Number: 105-0230
• Device Lot Number: T0010
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 09/19/2024
• Initial Report FDA Received Date: 10/10/2024
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 04/01/2022
• 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
• Concomitant Medical Products and Therapy/Usage Dates: PART: 103-0803 LOT: T1526; PART: 105-3610 LOT: U0080; PART: 105-4518 LOT: S0506; PART: 108-4520 LOT: U1214; PART: 108-4535 LOT: T0082; PART: 109-4535 LOT: S2300; PART: 109-4535 LOT: U0385
• Outcome Attributed to Adverse Event: Hospitalization; Required Intervention
• Patient Age: 56 YR
• Patient Sex: Unknown