MAUDE Adverse Event Report: TORNIER S.A.S. AEQUALIS REVERSED BASEPLATE; SHOULDER JOINT METAL PROSTHESIS

Model Number	DIAMETER 25 MM
Medical Device Problem Code	Device Dislodged or Dislocated (2923)
Health Effect - Clinical Code	Joint Dislocation (2374)
Date of Event	01/08/2019
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
The initial surgery on the left shoulder was held on (b)(6) 2018.The base plate was dislocated on (b)(6) 2019, and revision surgery was performed on (b)(6) 2019.On (b)(6), the fracture of the glenoid cavity due to dislocation was confirmed during revision surgery.The bone graft was done in the glenoid cavity, and the humerus side was treated with a cement type containing antibiotics.After about six months follow-up, the surgeon will decide whether to replace the base plate while watching the recovery status of the bone.
Additional Manufacturer Narrative
This is the final report submitted regarding this surgical event and medical device.

• Brand Name: AEQUALIS REVERSED BASEPLATE
• Common Device Name: SHOULDER JOINT METAL PROSTHESIS
• Manufacturer (Section D): TORNIER S.A.S.; 161 rue lavoisier; montbonnot saint-martin, 38330 ; FR 38330
• MDR Report Key: 8315276
• Report Number: 3000931034-2019-00021
• Device Sequence Number: 154553
• Product Code: KWS
• UDI-Device Identifier: 03700386935947
• UDI-Public: 03700386935947
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: K081059
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2018
• Device Explanted Year: 2019
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 01/10/2019

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: No Information
• Device Expiration Date: 06/18/2023
• Device Model Number: DIAMETER 25 MM
• Device Catalogue Number: DWD170
• Device Lot Number: 8069AT
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 01/10/2019
• Supplement Date Received by Manufacturer: 01/10/2019
• Initial Report FDA Received Date: 02/07/2019
• Supplement Report FDA Received Date: 08/21/2019
• 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: 79 YR