MAUDE Adverse Event Report: ENCORE MEDICAL L.P. ALTIVATE SHOULDER; ENCORE REVERSE SHOULDER HUMERAL STEM, STD, SZ14X108MM

Model Number	530-14-108
Health Effect - Clinical Code	No Code Available (3191)
Date of Event	02/14/2018
Type of Reportable Event	Serious Injury
Event or Problem Description
Second revision surgery - the patient was converted from turon total shoulder to altivate reverse, and initially did very well but became very tight and stiff following surgery.The decision was made to revise to a more medialized glenosphere and a looser construct, achieved by repositioning the humeral stem to take tension off of deltoid.
Additional Manufacturer Narrative
The reason for this revision surgery was due to shoulder tightness and stiffness.The previous surgery and the revision detailed in this investigation occurred over 3 months apart.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 disability/permanent damage and that 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 a non-conforming material report (ncmr) # (b)(4) associated with the part 530-14-108, altivate reverse humeral stem, standard shell, size 14, machined which documents a nonconformance that out of (b)(4) quantity lot 1 item was scrapped due to the defect in the porous coating.Remaining all items in the lot met the fit, design and functional requirements and were accepted.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 shoulder tightness and stiffness.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 multiple factors that may contribute to the event that are outside the control of djo surgical such as: aging of the patient, muscle stiffness, improper surgical technique, patient activities or trauma.Inventory containment is not required as 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, SZ14X108MM
• Manufacturer (Section D): ENCORE MEDICAL L.P.; 9800 metric blvd; austin TX 78758 5445
• MDR Report Key: 7293317
• Report Number: 1644408-2018-00168
• Device Sequence Number: 13747398
• Product Code: PHX
• UDI-Device Identifier: 00888912168489
• UDI-Public: (01)00888912168489
• Combination Product (Y/N): N
• Initial Reporter State: SC
• Initial Reporter Country: US
• PMA/510(K) Number: K141990
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2017
• Device Explanted Year: 2018
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 03/09/2018

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 Expiration Date: 10/09/2023
• Device Model Number: 530-14-108
• Device Catalogue Number: 530-14-108
• Device Lot Number: 415T1123
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Initial Date Received by Manufacturer: 02/14/2018
• Supplement Date Received by Manufacturer: 03/09/2018
• Initial Report FDA Received Date: 02/23/2018
• Supplement Report FDA Received Date: 03/09/2018
• 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: 508-32-103, LOT 864C2761; 509-00-032, LOT 377P1207; 508-32-103, LOT 864C2761; 509-00-032, LOT 377P1207
• Outcome Attributed to Adverse Event: Required Intervention; Disability
• Patient Age: 71 YR