MAUDE Adverse Event Report: TORNIER S.A.S. AEQUALS REVERSED LATERALIZED HUMERAL INSERT; SHOULDER JOINT POLYMER PROSTHESIS

Model Number	DIA.42 MM X 6MM
Medical Device Problem Code	Device Dislodged or Dislocated (2923)
Health Effect - Clinical Code	Patient Problem/Medical Problem (2688)
Date of Event	10/10/2016
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
This is the initial report submitted regarding this surgical event and medical device.
Event or Problem Description
"it was reported that a patient underwent a revision surgery one month post-operative (total shoulder replacement) due to anterior dislocation of reversed shoulder.Patient id: (b)(6).
Additional Manufacturer Narrative
This is the final report submitted regarding this surgical event and medical device.
Event or Problem Description
It was reported that a patient underwent a revision surgery one month post-operative (total shoulder replacement) due to anterior dislocation of reversed shoulder.Explantation of the humeral insert only.Patient id : (b)(6).

• Brand Name: AEQUALS REVERSED LATERALIZED HUMERAL INSERT
• Common Device Name: SHOULDER JOINT POLYMER PROSTHESIS
• Manufacturer (Section D): TORNIER S.A.S.; 161 rue lavoisier; montbonnot saint-martin, 38330 ; FR 38330
• MDR Report Key: 7193175
• Report Number: 3000931034-2018-00004
• Device Sequence Number: 11228341
• Product Code: KWS
• UDI-Device Identifier: 03700386916151
• UDI-Public: 03700386916151
• Combination Product (Y/N): N
• Initial Reporter State: MN
• Initial Reporter Country: US
• PMA/510(K) Number: K050316
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2016
• Device Explanted Year: 2016
• Reporter Type: Manufacturer
• Report Source: study
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 12/20/2017

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: Physician
• Device Expiration Date: 08/21/2020
• Device Model Number: DIA.42 MM X 6MM
• Device Catalogue Number: DWB996
• Device Lot Number: 2744AQ
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Initial Date Received by Manufacturer: 12/20/2017
• Supplement Date Received by Manufacturer: 12/20/2017
• Initial Report FDA Received Date: 01/16/2018
• Supplement Report FDA Received Date: 06/14/2018
• 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: Other
• Patient Age: 77 YR
• Patient Weight: 110