MAUDE Adverse Event Report: ENCORE MEDICAL L.P. ALTIVATE SHOULDER; ALTIVATE REVERSE, HUMERAL STEM, SMALL SHELL, SZ 6X175MM

Model Number	533-06-175
Health Effect - Clinical Code	No Code Available (3191)
Date of Event	04/05/2019
Type of Reportable Event	Serious Injury
Event or Problem Description
Second revision surgery - due to the patient dislocating for the 2nd time.The surgeon was unable to make shoulder joint stable.The surgeon pulled all humeral implants and left nothing.
Additional Manufacturer Narrative
Corrected data: see concomitant medical products.Concomitant part 509-02-032, lot 951w1057 should not have been reported on the initial medical device report.It was removed during the first revision surgery reported on 1644408-2019-00054.Manufacturer narrative: the reason for this second revision surgery was dislocation.The previous surgery and the surgery detailed in this investigation occurred 3 months apart.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 implant device history records (dhr), shows that the reported component used in the previous surgery, when released for use, met design and manufacturing requirements.There were no non-conforming material reports associated with the product that may have contributed to the reported event.The device was verified to have gone through an acceptable sterilization process and was within its expiration date at the time of 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 dislocating.There were no findings during this investigation that indicate that the reported device was defective.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 event.There are multiple factors that may contribute to an event 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: ALTIVATE SHOULDER
• Common Device Name: ALTIVATE REVERSE, HUMERAL STEM, SMALL SHELL, SZ 6X175MM
• Manufacturer (Section D): ENCORE MEDICAL L.P.; 9800 metric blvd; austin TX 78758 5445
• MDR Report Key: 8574573
• Report Number: 1644408-2019-00381
• Device Sequence Number: 19429795
• Product Code: KWS
• UDI-Device Identifier: 00190446259107
• UDI-Public: (01)00190446259107
• Combination Product (Y/N): N
• Initial Reporter State: OH
• Initial Reporter Country: US
• PMA/510(K) Number: K172351
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2019
• Device Explanted Year: 2019
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 07/05/2019

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: Health Professional
• Device Expiration Date: 01/26/2024
• Device Model Number: 533-06-175
• Device Catalogue Number: 533-06-175
• Device Lot Number: 924W1001
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 04/05/2019
• Supplement Date Received by Manufacturer: 06/05/2019
• Initial Report FDA Received Date: 05/02/2019
• Supplement Report FDA Received Date: 07/05/2019
• 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: 508-02-032, LOT 983W1020; 508-02-032, LOT 983W1020; 509-02-032, LOT 951W1057; 533-08-000, LOT 004Y1012; 533-08-000, LOT 004Y1012; 508-02-032, LOT 983W1020; 509-02-032, LOT 951W1057; 533-08-000, LOT 004Y1012
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 74 YR