MAUDE Adverse Event Report: ENCORE MEDICAL L.P. ALTIVATE SHOULDER; ENCORE REVERSE SHOULDER HUMERAL STEM, STD, SZ10X175MM

Model Number	530-10-175
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	02/07/2018
Type of Reportable Event	Serious Injury
Event or Problem Description
Revision surgery - the patient had a djo long stem removed due to it being loose.The surgeon then dropped a size from a 10x175 to an 8x175 and cemented the stem.The surgeon used fibular allograft for support.
Additional Manufacturer Narrative
The reason for this revision surgery was due to the long stem becoming loose.The actual length of in-vivo for the item listed is unknown as the original surgery date was not provided or could be established.There is no information in this complaint about any patient injuries, activities, or accidents that may have contributed to the need for this revision surgery.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 device history records (dhr) was not conducted since the item and or lot number was not provided or determined during the complaint evaluation.Given the limited information, extensive search for an invoice of the previous surgery produced no results.Should additional information become available this investigation will be re-opened for further evaluation.The root cause of this complaint was a revision surgery due to the long stem becoming loose.Inventory containment is not required since there are no indications of a product or process issue affecting implant safety or effectiveness.

• Brand Name: ALTIVATE SHOULDER
• Common Device Name: ENCORE REVERSE SHOULDER HUMERAL STEM, STD, SZ10X175MM
• Manufacturer (Section D): ENCORE MEDICAL L.P.; 9800 metric blvd; austin TX 78758 5445
• MDR Report Key: 7267941
• Report Number: 1644408-2018-00136
• Device Sequence Number: 1455834
• Product Code: PHX
• UDI-Device Identifier: 00888912168373
• UDI-Public: (01)00888912168373
• Combination Product (Y/N): N
• Initial Reporter State: CA
• Initial Reporter Country: US
• PMA/510(K) Number: K141990
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Explanted Year: 2018
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 04/05/2018

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 Model Number: 530-10-175
• Device Catalogue Number: 530-10-175
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Initial Date Received by Manufacturer: 02/07/2018
• Supplement Date Received by Manufacturer: 03/22/2018; 04/05/2018
• Initial Report FDA Received Date: 02/13/2018
• Supplement Report FDA Received Date: 03/23/2018; 04/05/2018
• 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: 803-04-140; 803-04-140
• Outcome Attributed to Adverse Event: Required Intervention