|
As reported, approximately 2 months and 15 days post the initial right reverse total shoulder arthroplasty, it appeared that the glenosphere had loosened/not been implanted properly and wear evidence were shown on the liner and humerus.The patient was revised.Everything was removed and a new reverse shoulder was implanted.There was no reported breakage of a device or surgical delay/prolongation.The patient was last known to be in stable condition following the event.
|
|
D10: (b)(6) 300-30-08 - equinoxe preserve stem 8mm.(b)(6) 315-35-00 - glnd kwire.(b)(6) 320-01-38 - equinoxe reverse 38mm glenosphere.(b)(6) 320-10-00 - equinoxe reverse tray adapter plate tray +0.(b)(6) 320-20-00 - eq reverse torque defining screw kit.(b)(6) 320-20-26 - eq rev compress screw lck cap kit, 4.5 x 26mm.(b)(6) 320-20-30 - eq rev compress screw lck cap kit, 4.5 x 30mm.(b)(6) 320-20-34 - eq rev compress screw lck cap kit, 4.5 x 34mm.(b)(6) 321-52-07 - 3.2mm drill bit sterile.No device was returned for evaluation; the reported event was confirmed by review of radiograph images provided.The review identified that based on the provided imaging it appears that the glenosphere is not seated fully on the glenoid baseplate.Based on the length of time the devices have been implanted, it is likely that the glenosphere locking screw was not fully seated during the time of implantation, resulting in the observed loosening of the glenosphere.Per the equinoxe shoulder primary reverse operative technique, optech-000160 rev a, when implanting the glenosphere, ¿run an instrument along the backside of the glenosphere to feel for the plate.You should not feel any of the plate if the glenosphere is seated properly.¿ images of the explanted devices were provided.There appears to be abrasive wear on the articular surface of the explanted humeral liner.This wear appears consistent with abnormal articulation between the humeral liner and edge of a misassembled glenosphere.However, this cannot be confirmed from the information provided.The humeral components appear unremarkable for explanted components.Additionally, there appears to be an unbroken torque defining screw.Based on the provided information, it does not appear that this torque screw had been implanted prior to this revision.Operative notes and/or medical records were not provided for review of usage/ technique.A review of manufacturing data was performed and no discrepancies were found.A review of complaint history determined that no further action is required as no trends were identified.A definitive root cause was unable to be determined; however, may have resulted from device-device loosening of the glenosphere/glenosphere locking screw from the glenoid baseplate.This may have been due to incomplete initial seating of the glenosphere locking screw at the time of implantation.The wear observed on the explanted humeral liner was likely due to abnormal articulation between the humeral liner and glenosphere secondary to the incomplete seating of the locking screw.However, the cause of the prosthesis wear cannot be confirmed and potential contributions of patient-related considerations to the event could not be assessed as the devices were not returned for evaluation.If any further information is obtained that would change or alter any information provided, a supplemental report will be filed accordingly.
|