MAUDE Adverse Event Report: ENCORE MEDICAL L.P. REVERSE SHOULDER PROSTHESIS (RSP) SHOULDER; RSP, REVISION HUMERAL MONOBLOCK, 8MM X 175

Model Number	510-08-175
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	05/22/2019
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The reason for this revision surgery was due to device loosening.The previous surgery and the revision detailed in this investigation occurred 4.1 years 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 (ncmrs) 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 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 device loosening.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.
Event or Problem Description
Revision surgery - patient.Came to surgeon with 4 proximal humerus fracture.Surgeon used a size 8 monoblock stem and became loose overtime.Pulled 8 mm x 175 and used 10 mm x 175 altivate with cement, 8 mm spacer and +4 semi insert.

• Brand Name: REVERSE SHOULDER PROSTHESIS (RSP) SHOULDER
• Common Device Name: RSP, REVISION HUMERAL MONOBLOCK, 8MM X 175
• Manufacturer (Section D): ENCORE MEDICAL L.P.; 9800 metric blvd; austin TX 78758 5445
• MDR Report Key: 8723874
• Report Number: 1644408-2019-00566
• Device Sequence Number: 2472400
• Product Code: PHX
• UDI-Device Identifier: 00888912144728
• UDI-Public: (01)00888912144728
• Combination Product (Y/N): N
• Initial Reporter State: CA
• Initial Reporter Country: US
• PMA/510(K) Number: K100741
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2015
• Device Explanted Year: 2019
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 06/19/2019

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 Model Number: 510-08-175
• Device Catalogue Number: 510-08-175
• Device Lot Number: UNKNOWN
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 05/22/2019
• Initial Report FDA Received Date: 06/21/2019
• 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: 509-00-432. LOT # UNKNOWN
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 80 YR