MAUDE Adverse Event Report: ENCORE MEDICAL L.P. DJO SURGICAL; ALTIVATE REV REVISION MOD BASEPLATE AND TAPER KIT, 8.0MM WDG

Catalog Number	508-80-001
Medical Device Problem Codes	Detachment of Device or Device Component (2907); Patient Device Interaction Problem (4001)
Health Effect - Clinical Codes	Foreign Body In Patient (2687); Joint Laxity (4526)
Date of Event	01/27/2026
Type of Reportable Event	Serious Injury
Event or Problem Description
Revision surgery - due to glenoid wall collapsed, broken fragmented piece left in the patient.
Additional Manufacturer Narrative
Complaint has been evaluated and is similar to report number 1644408-2025-00940; 508-65-001, s800 - revision surgery, revision surgery.If additional information regarding the reported event is submitted at a future date, this investigation will be re-evaluated.
Additional Manufacturer Narrative
This supplemental report was create to update the evauation in h11.The agent reported "glenoid wall collapsed" the previous surgery and the surgery detailed in this event occurred 3mo.Apart.Item number: 508-80-001.Item description: altivate rev revision mod baseplate and taper kit, 8.0mm wdg.Lot number: 5017a1029.Part revision: a.Product type: shoulder.Manufacture date: 9/23/24.Expiration date: 9/17/29.This evaluation is limited in scope as the item(s) associated with this investigation was not returned to djo surgical - austin for examination.The surgery was completed as intended and without incident.If additional information regarding the reported event is submitted at a future date, this investigation will be re-evaluated.There was no information submitted with this complaint about any patient activities, accidents, or medical contraindications that may have contributed to the reported event.There were no findings during this evaluation that indicate that the reported device(s) was defective.The surgeon performed this procedure to remedy the patient's condition.No further action is deemed necessary.Root cause: the root cause of this complaint was a revision surgery due to glenoid wall collapsed.No information was submitted with the complaint regarding pre-existing conditions of the patient or any activities the patient was involved in that may have contributed to the event.There are multiple factors that may contribute to an event that are outside of the control of djo surgical.Containment: inventory containment is not required as there are no indications of a product or process issue affecting implant safety or effectiveness.The revision surgery was completed successfully.Device history records review: a review of the device history record(s) show that the reported component(s) used in the previous surgery, when released for use, met design and manufacturing requirements.There were no nonconforming material reports associated with the product(s) that may have contributed to the reported event.The device(s) was verified to have gone through an acceptable sterilization process and was within its expiration date at the time of the previous surgery.Complaint history: customer complaint history of the reported device(s) showed no present trends or on-going issues that are needing a review.

• Brand Name: DJO SURGICAL
• Common Device Name: ALTIVATE REV REVISION MOD BASEPLATE AND TAPER KIT, 8.0MM WDG
• 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: 24437604
• Report Number: 1644408-2026-00285
• Device Sequence Number: 10364757
• Product Code: KWS
• Combination Product (Y/N): N
• Initial Reporter State: UT
• Initial Reporter Country: US
• PMA/510(K) Number: K233481
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2025
• Device Explanted Year: 2026
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial,Followup

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?: Yes
• Operator of Device: Health Professional
• Device Catalogue Number: 508-80-001
• Device Lot Number: 5017A1029
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 01/27/2026
• Supplement Date Received by Manufacturer: 04/10/2026
• Initial Report FDA Received Date: 02/24/2026
• Supplement Report FDA Received Date: 05/06/2026
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 09/23/2024
• 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
• Concomitant Medical Products and Therapy/Usage Dates: 506-04-122 LOT: 5035A1013.; 506-04-126 LOT: 5037A1002.; 506-04-130 LOT: 5039A1007.; 506-04-130 LOT: 5039A1033.; 508-40-201 LOT: 4480A1041.; 508-80-030 LOT: 5027A1001C.; 509-01-440 LOT: 391P1164.; 510-08-000 LOT: 142G1647.
• Outcome Attributed to Adverse Event: Other
• Patient Sex: Unknown