MAUDE Adverse Event Report: ENCORE MEDICAL L.P. RSP SHOULDER; STEM, HUMERAL, LONG, REVISION, RSP, SIZE8

Model Number	507-08-175
Health Effect - Clinical Code	Pain (1994)
Date of Event	09/17/2018
Type of Reportable Event	Serious Injury
Event or Problem Description
Revision surgery - due to the stem being loose and causing pain.The surgeon removed the stem, cup and liner as well as the original glenosphere.He removed the cement mantel and replaced with a size 12 primary monoblock cemented stem.Replaced the 36 neutral glenosphere with a 32 neutral for more offset and built the poly to a +12.
Additional Manufacturer Narrative
The reason for this revision surgery was due to the pain.The previous surgery and the revision detailed in this investigation occurred 2.5 years 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 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 (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 pain.There were no findings during this investigation that indicate that the reported device was the source or had a direct connection with the event.Agent has clearly mentioned that "the stem was loose causing pain." it seems that the event may occurred due to inadequate soft tissue support, degenerative bone, patient bone deterioration, excessive range of motion, 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.
Additional Manufacturer Narrative
D10 - adding concomitant part 402283.

• Brand Name: RSP SHOULDER
• Common Device Name: STEM, HUMERAL, LONG, REVISION, RSP, SIZE8
• Manufacturer (Section D): ENCORE MEDICAL L.P.; 9800 metric blvd; austin TX 78758 5445
• Manufacturer (Section G): ENCORE MEDICAL L.P.; 9800 metric blvd; austin TX 78758 5445
• Manufacturer Contact: teffany hutto ; 9800 metric blvd; austin, TX 78758-5445
• MDR Report Key: 7935055
• Report Number: 1644408-2018-00903
• Device Sequence Number: 930769
• Product Code: PHX
• UDI-Device Identifier: 00888912144087
• UDI-Public: (01)00888912144087
• Combination Product (Y/N): N
• Initial Reporter State: VA
• Initial Reporter Country: US
• PMA/510(K) Number: K041066
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2016
• Device Explanted Year: 2018
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 05/27/2022

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: 07/31/2016
• Device Model Number: 507-08-175
• Device Catalogue Number: 507-08-175
• Device Lot Number: 844C1001
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 09/17/2018
• Supplement Date Received by Manufacturer: 10/08/2018; 10/08/2018
• Initial Report FDA Received Date: 10/04/2018
• Supplement Report FDA Received Date: 10/08/2018; 05/27/2022
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 07/13/2010
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: 402283 COBALT G-HV BONE CEMENT 40G; 508-00-000, LOT 848C1973; 508-01-036, LOT 860C1018; 508-36-101, LOT 869C2038
• Outcome Attributed to Adverse Event: Required Intervention; Other
• Patient Age: 70 YR
• Patient Sex: Male