MAUDE Adverse Event Report: FX Shoulder Solutions Dallas FX V135 Humelock; Reverse shoulder prosthesis

Catalog Number	105-3613
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Joint Dislocation (2374)
Date of Event	07/10/2026
Type of Reportable Event	Serious Injury
Event or Problem Description
Revision occurred on (b)(6) 2026 approximately 465 days after the primary surgery which occurred on (b)(6) 2025.No fall or other trauma was reported.Based on comparing usage forms only humelock reversed eccentric glenosphere w/ screw cocr/ta6v 10° tilt ø36mm, humeral cup 135/145° standard pe/ta6v ø36 +9 and humelock reversed ta6v cementless glenoid baseplate w/ screw ti/ha ø24mm, +3mm lateralized was explanted due to dislocation and replaced with reversed adapter ta6v 135/145,° humeral cup stability pe/ta6v ø36/+3, double taper ta6v +0mm 0° and centered head cocr 50x19.
Additional Manufacturer Narrative
Revision occurred approximately 465 days after the primary surgery due to dislocation of unknown cause.No actual, implied or suspect link to fx product.

• 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, TX 75001 ; +1(800)280-0775
• MDR Report Key: 50104916
• Report Number: 3014128390-2026-00036
• Device Sequence Number: 17466495
• Product Code: PHX
• UDI-Device Identifier: 03701037300275
• UDI-Public: 03701037300275
• Combination Product (Y/N): N
• Initial Reporter State: TX
• 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): 07/31/2026

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: 105-3613
• Device Lot Number: U1348
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 07/10/2026
• Initial Report FDA Received Date: 07/31/2026
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 12/01/2023
• 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 No: 105-0029 Lot No: T2654; Part No: 313-0709 Lot No: T1113
• Outcome Attributed to Adverse Event: Hospitalization; Required Intervention
• Patient Sex: Unknown