MAUDE Adverse Event Report: DEPUY IRELAND ¿ 9616671 GLOBAL UNITE BODY SZ 10 0; SHOULDER HUMERAL STEM/EPIPHYSIS

Catalog Number	110030110
Medical Device Problem Code	Appropriate Device Problem Term/Code Not Available (3191)
Health Effect - Clinical Code	No Information (3190)
Date of Event	06/27/2017
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.
Event or Problem Description
Der stated that the surgeon tried to convert from unite fx to reverse.The proximal body screw was loosened up and body would not release from the unite stem.Then the stem came out when trying to remove the body.They had to put in delta system.
Additional Manufacturer Narrative
The device associated with this report was not returned.Depuy considers the investigation closed.Should additional information be received, the information will be reviewed and the investigation will be re-opened as necessary.If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.

• Brand Name: GLOBAL UNITE BODY SZ 10 0
• Common Device Name: SHOULDER HUMERAL STEM/EPIPHYSIS
• Manufacturer (Section D): DEPUY IRELAND ¿ 9616671; loughbeg, ringaskiddy co.; cork, munster ; EI
• MDR Report Key: 6743871
• Report Number: 1818910-2017-21795
• Device Sequence Number: 1371440
• Product Code: HSD
• UDI-Device Identifier: 10603295004394
• UDI-Public: 10603295004394
• Combination Product (Y/N): N
• Initial Reporter State: NC
• Initial Reporter Country: US
• PMA/510(K) Number: K101996
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2016
• Device Explanted Year: 2017
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 06/27/2017

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: 110030110
• Device Lot Number: 8266423
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 06/27/2017
• Supplement Date Received by Manufacturer: 08/22/2017
• Initial Report FDA Received Date: 07/26/2017
• Supplement Report FDA Received Date: 08/22/2017
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 69 YR
• Patient Weight: 59