MAUDE Adverse Event Report: ENCORE MEDICAL L.P RSP SHOULDER; RSP, PRIMARY HUMERAL MONOBLOCK, 8MM X 108

Model Number	510-00-008
Health Effect - Clinical Code	Bone Fracture(s) (1870)
Date of Event	08/02/2017
Type of Reportable Event	Serious Injury
Event or Problem Description
Revision surgery - due to the patient's monoblock stem being loose and the patient fracturing her humerus.The surgeon took the reverse shoulder out and implanted in a long turon stem and humeral head.
Additional Manufacturer Narrative
Corrected data: the spacer and insert concomitant parts were not reported and have been added.
Additional Manufacturer Narrative
The reason for this revision surgery was due to the patient's monoblock stem being loose and the patient fracturing her humerus.The previous surgery and the revision detailed in this investigation occurred 2.1 years apart.There are no reported pre-existing patient health conditions.The healthcare professional indicated there was no delay in surgery and another suitable device was available for use.The revision surgery was completed as intended.The device was disposed of at the hospital and not made available to djo surgical for examination.A review of the implant device history records (dhr) shows that the reported component used in the previous surgery met design and manufacturing requirements.There were no non-conforming material reports (ncmrs) associated with the product that may have contributed to the event.The device was within its expiration date at the time of use during the previous surgery.Customer complaint history of the reported device showed no present trends or on-going issues that are in need of review.The root cause of this complaint was a revision surgery due to the monoblock stem loosening.There were no findings during this investigation that indicate that the reported device was the source or had a direct connection with the event.There are many factors that may contribute to the event that are outside the control of djo surgical such as: loose joints from inadequate soft tissue support and patient bone deterioration.No additional information was submitted with the complaint regarding pre-existing conditions of the patient or any activities that may have contributed to the event and hence a definitive root cause cannot be determined.Inventory containment is not required as there are no indications of a product or process issue affecting implant safety or effectiveness.

• Brand Name: RSP SHOULDER
• Common Device Name: RSP, PRIMARY HUMERAL MONOBLOCK, 8MM X 108
• Manufacturer (Section D): ENCORE MEDICAL L.P; 9800 metric blvd; austin TX 78758 5445
• MDR Report Key: 6835145
• Report Number: 1644408-2017-00721
• Device Sequence Number: 10792162
• Product Code: KWS
• UDI-Device Identifier: 00888912024815
• UDI-Public: (01)00888912024815
• Combination Product (Y/N): N
• Initial Reporter State: OH
• Initial Reporter Country: US
• PMA/510(K) Number: K100741
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2015
• Device Explanted Year: 2017
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 11/03/2017

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 Expiration Date: 05/31/2021
• Device Model Number: 510-00-008
• Device Catalogue Number: 510-00-008
• Device Lot Number: 979F1195
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Initial Date Received by Manufacturer: 08/02/2017
• Supplement Date Received by Manufacturer: 09/26/2017; 11/03/2017
• Initial Report FDA Received Date: 08/31/2017
• Supplement Report FDA Received Date: 10/24/2017; 11/03/2017
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: 506-02-118, LOT 820C1002; 506-02-126, LOT 824C1012; 506-03-122, LOT 833C1181; 506-03-126, LOT 834C1206; 508-32-101, LOT 862C1974; 508-32-104, LOT 866C1951
• Outcome Attributed to Adverse Event: Required Intervention