MAUDE Adverse Event Report: ENCORE MEDICAL L.P. FOUNDATION SHOULDER; GLENOID, UNIFORM, PEGGED 42MM CM FOUNDATION SHOULDER

Model Number	500-04-142
Health Effect - Clinical Code	Unspecified Infection (1930)
Date of Event	08/30/2018
Type of Reportable Event	Serious Injury
Event or Problem Description
Revision surgery - due to the patient's shoulder being infected.The surgeon removed the components and implanted cement spacers.
Additional Manufacturer Narrative
The reason for this revision surgery was due to an infection.The previous surgery and the revision detailed in this investigation occurred 4.5 years apart.No information was submitted with the complaint regarding pre-existing conditions of the patient or any activities the patient was involved in that may have contributed to the infection or inhibited the patient's immune system.The healthcare professional indicated there was a serious risk to the patient.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 (dhrs) show 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 an infection.Customer complaint history of the reported device showed no present trends or on-going issues that are in need of review.The device was verified to have gone through an acceptable sterilization process and was within it's expiration date at the time of use during the previous surgery.There were no findings during this investigation that indicate that the reported device was the root cause or had a direct connection with the patient's infection.There are multiple factors that may contribute to an infection that are outside of the control of djo surgical.There are no indications of a product or process issue affecting implant safety or effectiveness.

• Brand Name: FOUNDATION SHOULDER
• Common Device Name: GLENOID, UNIFORM, PEGGED 42MM CM FOUNDATION SHOULDER
• Manufacturer (Section D): ENCORE MEDICAL L.P.; 9800 metric blvd; austin TX 78758 5445
• MDR Report Key: 7907480
• Report Number: 1644408-2018-00905
• Device Sequence Number: 1585861
• Product Code: KWS
• UDI-Device Identifier: 00888912143196
• UDI-Public: (01)00888912143196
• Combination Product (Y/N): N
• Initial Reporter State: RI
• Initial Reporter Country: US
• PMA/510(K) Number: K960906
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2014
• Device Explanted Year: 2018
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 10/12/2018

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: 11/28/2015
• Device Model Number: 500-04-142
• Device Catalogue Number: 500-04-142
• Device Lot Number: 741C1004
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 08/30/2018
• Supplement Date Received by Manufacturer: 10/12/2018
• Initial Report FDA Received Date: 09/25/2018
• Supplement Report FDA Received Date: 10/12/2018
• 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: 520-00-000, LOT 878C1309; 520-01-010, LOT 455C1106; 520-46-116, LOT 923C1051
• Outcome Attributed to Adverse Event: Other; Required Intervention
• Patient Age: 74 YR