MAUDE Adverse Event Report: ARTHREX, INC. HUMERAL INSERT S/36 +3 TO FIT IN 36 CUP; SHOULDR PROSTH, REVERSE CONFIG

Model Number	HUMERAL INSERT S/36 +3 TO FIT IN 36 CUP
Medical Device Problem Code	Positioning Failure (1158)
Health Effect - Clinical Code	Insufficient Information (4580)
Date of Event	10/14/2024
Type of Reportable Event	Malfunction
Event or Problem Description
On 10/16/2024, it was reported by a sales representative via email that two ar-9501-05p univers revers humeral stem and two ar-9502f-36cpc arthrex univers revers suture cups engaged correctly, but they were loose, along with the two ar-9503s-03 univers revers humeral insert in between.The surgeon could wiggle the implants and make them move.The screw of the two ar-9502f-36cpc arthrex univers revers suture cups was not engaging with both ar-9501-05p univers revers humeral stem.The case was completed by opening a different ar-9501-05p univers revers humeral stem, an ar-9502f-36cpc arthrex univers revers suture cup, and an ar-9503s-03 univers revers humeral insert from a different lot number.This was discovered when putting the products together before insertion in the patient during a rtsa procedure on (b)(6) 2024.The case was delayed fifteen minutes; however, it is unknown if additional anesthesia was updated.
Additional Manufacturer Narrative
Investigation is in process.A follow-up report will be provided upon availability of additional information.
Additional Manufacturer Narrative
Additional information: d9, g3, h3, h6.The complaint allegation is confirmed.One ar-9503s-03, univers revers¿ humeral insert small, was received, assembled with an ar-9501-05p and ar-9502f-36cpc.Visual evaluation noted that the stem, the suture cup and humeral insert were stuck together.Additionally, the insert had gauge marks along the side.Functional testing noted that while the devices are assembled, the stem did not sit flush to the suture cup and could be wiggled to either side.It is likely that the screw was not reinforced to sit flush.The most likely cause is attributed to misuse due to user error due to not following the correct surgical technique.

• Brand Name: HUMERAL INSERT S/36 +3 TO FIT IN 36 CUP
• 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: 20559490
• Report Number: 1220246-2024-08312
• Device Sequence Number: 16916178
• Product Code: PHX
• UDI-Device Identifier: 00888867061293
• UDI-Public: 00888867061293
• Combination Product (Y/N): N
• Initial Reporter State: FL
• Initial Reporter Country: US
• PMA/510(K) Number: K142863
• 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,Followup
• Report Date (Section B): 01/31/2025

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: HUMERAL INSERT S/36 +3 TO FIT IN 36 CUP
• Device Catalogue Number: AR-9503S-03
• Device Lot Number: 23.05410
• Was Device Available for Evaluation?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 10/16/2024
• Supplement Date Received by Manufacturer: 01/06/2025
• Initial Report FDA Received Date: 10/29/2024
• Supplement Report FDA Received Date: 01/31/2025
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• 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