MAUDE Adverse Event Report: ENCORE MEDICAL L.P. DJO SURGICAL; BASEPLATE, GLENOID HA-COAT, RSP, 6.5MM X 30MM

Catalog Number	508-32-104
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Implant Pain (4561)
Date of Event	04/24/2025
Type of Reportable Event	Serious Injury
Event or Problem Description
Revision surgery - due to shoulder pain.
Additional Manufacturer Narrative
Complaint has been evaluated and is similar to report number 1644408-2022-00748; 508-32-104, s807 - pain, revision surgery.If additional information regarding the reported event is submitted at a future date, this investigation will be re-evaluated.

• Brand Name: DJO SURGICAL
• Common Device Name: BASEPLATE, GLENOID HA-COAT, RSP, 6.5MM X 30MM
• Manufacturer (Section D): ENCORE MEDICAL L.P.; 9800 metric blvd.; austin TX 78758
• Manufacturer (Section G): ENCORE MEDICAL L.P.; 9800 metric blvd.; austin TX 78758
• Manufacturer Contact: stacey bonnell ; 9800 metric blvd; austin, TX 78758 ; 5128346313
• MDR Report Key: 22032632
• Report Number: 1644408-2025-00644
• Device Sequence Number: 9412056
• Product Code: PHX
• UDI-Device Identifier: 00888912024754
• UDI-Public: 00888912024754
• Combination Product (Y/N): N
• Initial Reporter State: TX
• Initial Reporter Country: US
• PMA/510(K) Number: K051075
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2021
• Device Explanted Year: 2025
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 05/15/2025

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: Health Professional
• Device Expiration Date: 03/07/2026
• Device Catalogue Number: 508-32-104
• Device Lot Number: 866C2752
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 04/24/2025
• Initial Report FDA Received Date: 05/15/2025
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 03/18/2020
• 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: 506-03-114 LOT: 831C1790; 506-03-122 LOT: 833C1535; 506-03-130 LOT: 835C1714; 508-32-103 LOT: 864C4189; 509-03-432 LOT: 954W1105
• Outcome Attributed to Adverse Event: Other
• Patient Age: 81 YR
• Patient Sex: Female