MAUDE Adverse Event Report: FX SHOULDER SOLUTIONS DALLAS FX V135 HUMELOCK; REVERSE SHOULDER PROSTHESIS

Catalog Number	103-0803
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Joint Dislocation (2374)
Date of Event	04/15/2026
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Revision occurred approximately 252 days after the primary surgery due to dislocation of unknown cause.No actual, implied or suspect link to fx product.
Event or Problem Description
Revision occurred on (b)(6) 2026.All required information was received on 09-jun-2026.Revision occured approximately 252 days after the primary surgery which occurred on (b)(6) 2025.No fall or other trauma was reported.Based on comparing usage forms only humeral cup standard pe/ta6v ø36/+3 was explanted due to dislocation and replaced with humeral cup stability pe/ta6v ø36/+3 and fx v135 humeral spacer ta6v +9mm.Fx v135® humelock stem ta6v ø32/08 l.120mm cementless ti/ha was not replaced.

• Brand Name: FX V135 HUMELOCK
• Common Device Name: REVERSE SHOULDER PROSTHESIS
• Manufacturer (Section D): FX SHOULDER SOLUTIONS DALLAS; 15920 addison road; suite 200; addison TX 75001
• Manufacturer (Section G): FX SHOULDER SOLUTIONS DALLAS; 15920 addison road; suite 200; addison TX 75001
• Manufacturer Contact: seenath kabeer ; 15920 addison road; suite 200; addison 75001 ; 8002800775
• MDR Report Key: 25505619
• Report Number: 3014128390-2026-00023
• Device Sequence Number: 10589499
• Product Code: PHX
• UDI-Device Identifier: 03701037300091
• UDI-Public: 03701037300091
• Combination Product (Y/N): N
• Initial Reporter State: KY
• Initial Reporter Country: US
• PMA/510(K) Number: K150488
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2025
• Device Explanted Year: 2026
• 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): 06/15/2026

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 Catalogue Number: 103-0803
• Device Lot Number: V2339
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 04/15/2026
• Initial Report FDA Received Date: 06/15/2026
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 03/01/2025
• 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: Hospitalization; Required Intervention
• Patient Age: 69 YR
• Patient Sex: Female