MAUDE Adverse Event Report: TORNIER INC PERFORM HUMERAL STEM SZ 4; PROSTHESIS, SHOULDER, SEMI-CONSTRAINED, METAL/POLYMER + ADDITIVE, CEMENTED

Catalog Number	DWX4SS
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Fever (1858); Hematoma (1884); Pain (1994); Embolism/Embolus (4438); Thrombosis/Thrombus (4440)
Date of Event	02/08/2025
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Based on the available information the device will not be returned therefore an evaluation of the device cannot be performed.A review of the device history is not possible because the lot number was not communicated.Should additional information become available, it will be provided in a supplemental report.
Event or Problem Description
As reported: "subject: (b)(6).Study: shoulder id.Patient presented to ed (b)(6) 2025 s/p generalized weakness (slid to floor from chair) and fever and was found to have acute pe [pulmonary embolism].Patient hospitalized at (b)(6) beginning (b)(6) 2025.X-ray of r shoulder obtained in ed and showed intact hardware without complication.(b)(6) 2025 - hematoma - narrative : left lower quadrant (llq) abdominal pain secondary to large active rectus sheath hematoma in the setting of new anticoagulation therapy.Warfarin held and reversed w/ vitamin k.Pt remains hospitalized.(b)(6) 2025: acute deep venous thrombosis in left gastrocnemius veins.Pt remains hospitalized.Outcome: not recovered/not resolved".

• Brand Name: PERFORM HUMERAL STEM SZ 4
• Common Device Name: PROSTHESIS, SHOULDER, SEMI-CONSTRAINED, METAL/POLYMER + ADDITIVE, CEMENTED
• Manufacturer (Section D): TORNIER INC; 10801 nesbitt avenue s; bloomington MN 55437
• Manufacturer (Section G): WRIGHT MEDICAL CORK (TORNIER ORTHOPEDICS IRELAND LTD); harnetts cross; macroom, co. cork NA ; EI NA
• Manufacturer Contact: anna jusinski ; 325 corporate drive; mahwah, NJ 07430 ; 2018315000
• MDR Report Key: 21572491
• Report Number: 0001649390-2025-00129
• Device Sequence Number: 18250515
• Product Code: PAO
• UDI-Device Identifier: 00846832085514
• UDI-Public: 00846832085514
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K201315
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2025
• Reporter Type: Manufacturer
• Report Source: Health Professional
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 03/11/2025

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: Lay User/Patient
• Device Catalogue Number: DWX4SS
• Device Lot Number: UNKNOWN
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 02/10/2025
• Initial Report FDA Received Date: 03/11/2025
• 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: 74 YR
• Patient Sex: Male
• Patient Weight: 101 KG