MAUDE Adverse Event Report: TORNIER S.A.S. AEQ REVSD FRACTURE LATERALIZED HMRL INSERT DIA42MM THCK+6MM; SHOULDER PROSTHESIS, REVERSE CONFIGURATION

Catalog Number	DWD966
Medical Device Problem Codes	Unstable (1667); Device Dislodged or Dislocated (2923)
Health Effect - Clinical Codes	Joint Dislocation (2374); Joint Laxity (4526)
Date of Event	09/03/2025
Type of Reportable Event	Serious Injury
Event or Problem Description
It was reported that, the poly insert was revised due to dislocation/ instability.Patient factors contributing to dislocation were likely axillary nerve palsy and failure of tuberosity repair on right hand side.
Additional Manufacturer Narrative
Additional information has been requested and if received, will be provided in the supplemental report.
Additional Manufacturer Narrative
The reported event could not be confirmed since the device was not returned for evaluation and no other evidences were provided.A review of the device history for the reported lot did not indicate any abnormalities.No corrective actions are required at this time.A review of the labeling did not indicate any abnormalities.No indications of material, manufacturing or design related problems were found during the investigation.The following information was reported- patient factors contributing to dislocation were likely axillary nerve palsy and failure of tuberosity repair.However, while patient factors likely contributed to the event, it is not possible to confirm the exact root cause based solely on the information provided without supporting documentation or evidence such as medical records.More detailed information about the complaint event as well as the affected device must be available in order to determine the root cause of the complaint event.If the device is returned or if any additional information is provided, the investigation will be reassessed.
Event or Problem Description
It was reported that, the poly insert was revised due to dislocation/ instability.Patient factors contributing to dislocation were likely axillary nerve palsy and failure of tuberosity repair on right hand side.

• Brand Name: AEQ REVSD FRACTURE LATERALIZED HMRL INSERT DIA42MM THCK+6MM
• Common Device Name: SHOULDER PROSTHESIS, REVERSE CONFIGURATION
• Manufacturer (Section D): TORNIER S.A.S.; 161 rue lavoisier; montbonnot saint-martin 38330 ; FR 38330
• Manufacturer (Section G): TORNIER S.A.S.; 161 rue lavoisier; montbonnot saint-martin 38330 ; FR 38330
• Manufacturer Contact: dannielle stap ; 325 corporate drive; mahwah, NJ 07430 ; 2018315000
• MDR Report Key: 23185326
• Report Number: 3000931034-2025-00528
• Device Sequence Number: 10074773
• Product Code: PHX
• UDI-Device Identifier: 03700386936357
• UDI-Public: (01)03700386936357(11)241108(17)291108
• Combination Product (Y/N): N
• Initial Reporter Country: AS
• PMA/510(K) Number: K082120
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2025
• Device Explanted Year: 2025
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 12/17/2025

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: DWD966
• Device Lot Number: 1246BB
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Follow-Up
• Initial Date Received by Manufacturer: 09/03/2025
• Supplement Date Received by Manufacturer: 11/20/2025
• Initial Report FDA Received Date: 09/30/2025
• Supplement Report FDA Received Date: 12/17/2025
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 11/08/2024
• 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: 88 YR
• Patient Sex: Male