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

Catalog Number	105-0026
Medical Device Problem Code	Migration (4003)
Health Effect - Clinical Code	Inadequate Osseointegration (2646)
Date of Event	06/12/2025
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Revision occurred after 21 months due to loosening of components.No actual, implied, or suspect link to fx product.
Event or Problem Description
Revision occurred approximately 21 months after the prior revision surgery, which occurred on (b)(6) 2023.The primary surgery occurred on (b)(6) 2023.No fall or other trauma reported.Revision occurred due to loosening of the baseplate component.A 24 mm + 6 lateralized baseplate, 6 mm post extension, 40 mm eccentric glenosphere, 40 mm +3 humeral stability cup, 2 of 9 mm spacer, and 3 standard screws were explanted.These items were replaced with a competitor antibiotic spacer; fx components were listed on the usage form for the case but were all wasted.

• Brand Name: HUMELOCK REVERSED
• Common Device Name: REVERSE SHOULDER PROSTHESIS
• Manufacturer (Section D): FX SHOULDER SOLUTIONS DALLAS; 15920 addison road; addison TX 75001
• 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: 22341553
• Report Number: 3014128390-2025-00038
• Device Sequence Number: 18423590
• Product Code: PHX
• UDI-Device Identifier: 03701037316795
• UDI-Public: 03701037316795
• 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: 2025
• 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): 06/26/2025

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?: No
• Operator of Device: Health Professional
• Device Catalogue Number: 105-0026
• Device Lot Number: T1187
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 06/12/2025
• Initial Report FDA Received Date: 06/26/2025
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 12/01/2022
• 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: 103-0007 LOT: T2564; PART: 104-1003 LOT: T0966; PART: 105-0006 LOT: T2373; PART: 105-4011 LOT: N0047; PART: 109-4525 LOT: N1310; PART: 109-4530 LOT: U0676; PART: 109-4535 LOT: M2992
• Outcome Attributed to Adverse Event: Hospitalization; Required Intervention
• Patient Age: 74 YR
• Patient Sex: Unknown