BEUDAMED
    FDA Adverse Event Injury Summary report: N

    REVERSE HUMERAL SHELL L 40+0

    MDR report key: 22344392 · Received June 27, 2025

    Report

    Report Number
    1818910-2025-10745
    Event Type
    Injury
    Date Received
    June 27, 2025
    Date of Event
    May 28, 2025
    Manufacturer
    DEPUY IRELAND - 3015516266
    Product Code
    PHX
    UDI-DI
    10603295546962
    PMA / PMN Number
    K212737
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    US
    Reporter Occupation
    OTHER HEALTH CARE PROFESSIONAL
    Health Professional
    Yes

    Narratives

    Additional Manufacturer Narrative · 0

    PRODUCT COMPLAINT # (B)(4). THIS REPORT IS BEING SUBMITTED PURSUANT TO THE PROVISIONS OF 21 CFR, PART 803 (AND/OR PART 4, AS APPLICABLE). THIS REPORT MAY BE BASED ON INFORMATION WHICH HAS NOT BEEN INVESTIGATED OR VERIFIED PRIOR TO THE REQUIRED REPORTING DATE. THIS REPORT DOES NOT REFLECT A CONCLUSION BY DEPUY SYNTHES, OR ITS EMPLOYEES THAT THE REPORT CONSTITUTES AN ADMISSION THAT THE PRODUCT, DEPUY SYNTHES, OR ITS EMPLOYEES CAUSED OR CONTRIBUTED TO THE POTENTIAL EVENT DESCRIBED IN THIS REPORT. IF INFORMATION IS OBTAINED THAT WAS NOT AVAILABLE FOR THE INITIAL REPORT, A FOLLOW-UP REPORT WILL BE FILED AS APPROPRIATE. H11 ADDITIONAL NARRATIVE: D4: UDI: AS THE CATALOG/MODEL NUMBER WAS NOT PROVIDED, THE (01)GTIN IS NOT AVAILABLE.

    Additional Manufacturer Narrative · 0

    PRODUCT COMPLAINT #(B)(4). INVESTIGATION SUMMARY: NO DEVICE ASSOCIATED WITH THIS REPORT WAS RECEIVED FOR EXAMINATION. AN EVALUATION OF THE MANUFACTURING RECORD COULD NOT BE PERFORMED AS THE REQUIRED PRODUCT/LOT NUMBER WAS NOT PROVIDED TO COMPLETE THE EVALUATION. AS PART OF OUR COMPANY QUALITY SYSTEM PROCESS, ALL DEVICES ARE MANUFACTURED, INSPECTED, AND DISTRIBUTED TO APPROVED SPECIFICATIONS. ADDITIONAL COMPLAINT INFORMATION MONITORING FOR POTENTIAL SAFETY SIGNALS WILL BE CONDUCTED THROUGH COMPLAINT TRENDING AS PART OF THE POST-MARKET SURVEILLANCE. IF ADDITIONAL INFORMATION IS MADE AVAILABLE, THE INVESTIGATION WILL BE UPDATED AS APPLICABLE. DEVICE HISTORY LOT: THE DEVICE LOT NUMBER IS UNKNOWN; THEREFORE, A DEVICE HISTORY REVIEW COULD NOT BE PERFORMED. IF THE LOT/SERIAL NUMBER BECOMES AVAILABLE, THE RECORD WILL BE RE-ASSESSED.

    Additional Manufacturer Narrative · 0

    PRODUCT COMPLAINT #(B)(4). THIS REPORT IS BEING SUBMITTED PURSUANT TO THE PROVISIONS OF 21 CFR, PART 803. THIS REPORT MAY BE BASED ON INFORMATION WHICH HAS NOT BEEN INVESTIGATED OR VERIFIED PRIOR TO THE REQUIRED REPORTING DATE. THIS REPORT DOES NOT REFLECT A CONCLUSION BY DEPUY SYNTHES JOINT RECONSTRUCTION, OR ITS EMPLOYEES THAT THE REPORT CONSTITUTES AN ADMISSION THAT THE PRODUCT, DEPUY SYNTHES JOINT RECONSTRUCTION, OR ITS EMPLOYEES CAUSED OR CONTRIBUTED TO THE POTENTIAL EVENT DESCRIBED IN THIS REPORT. H11 ADDITIONAL NARRATIVE: ADDED: B5, D4 (CATALOG, LOT, EXPIRY DATE, PRIMARY UDI NUMBER), G4 [PMA/ 510(K)], H4 CORRECTED: D1, D2A, D2B, D3, 10 (CONCOMITANT), H6 (HEALTH EFFECT - CLINICAL CODE, MEDICAL DEVICE PROBLEM CODE). IF INFORMATION IS OBTAINED THAT WAS NOT AVAILABLE FOR THE INITIAL REPORT, A FOLLOW-UP REPORT WILL BE FILED AS APPROPRIATE.

    Additional Manufacturer Narrative · 0

    PRODUCT COMPLAINT # (B)(4). INVESTIGATION SUMMARY: NO DEVICE ASSOCIATED WITH THIS REPORT WAS RECEIVED FOR EXAMINATION. THE PRODUCT INVESTIGATION FOUND NO EVIDENCE SUSPECTING AN ERROR IN THE MANUFACTURING OR MATERIAL THAT WOULD BE A CONTRIBUTING FACTOR IN THE REPORTED ALLEGATION(S). A RECORDS EVALUATION (MRE) WAS NOT PERFORM. AS PART OF OUR COMPANY QUALITY SYSTEM PROCESS, ALL DEVICES ARE MANUFACTURED, INSPECTED, AND DISTRIBUTED TO APPROVED SPECIFICATIONS. ADDITIONAL COMPLAINT INFORMATION MONITORING FOR POTENTIAL SAFETY SIGNALS WILL BE CONDUCTED THROUGH COMPLAINT TRENDING AS PART OF THE POST-MARKET SURVEILLANCE. IF ADDITIONAL INFORMATION IS MADE AVAILABLE, THE INVESTIGATION WILL BE UPDATED AS APPLICABLE. DEVICE HISTORY LOT: THE PRODUCT INVESTIGATION FOUND NO EVIDENCE SUSPECTING AN ERROR IN THE MANUFACTURING OR MATERIAL THAT WOULD BE A CONTRIBUTING FACTOR IN THE REPORTED ALLEGATION(S). A MANUFACTURING RECORDS EVALUATION (MRE) WAS NOT PERFORMED.

    Description of Event or Problem · 0

    STUDY NO: (B)(6). CLINICAL ADVERSE EVENT RECEIVED FOR "FAILED LEFT REVERSE TOTAL SHOULDER ARTHROPLASTY WITH HUMERAL COMPONENT LOOSENING". DEVICE AND PROCEDURE (RELATEDNESS) RELATIONSHIP TO STUDY DEVICE: CAUSAL RELATIONSHIP NO RELATIONSHIP TO PRIMARY STUDY PROCEDURE: PROBABLE. DEVICE LOCATION: LEFT TREATMENT/IMPACT: SURGICAL INTERVENTION FOR THE STUDY SHOULDER: YES. SINGLE-STAGE REVISION: YES.

    Description of Event or Problem · 0

    ADDITIONAL INFORMATION RECEIVED: TREATMENT/IMPACT: SINGLE-STAGE REVISION, COMPONENTS REMOVED (HUMERAL STEMLESS IMPLANT: YES, REVERSE HUMERAL SHELL: YES, REVERSE LINER: YES) COMPONENTS IMPLANTED: STEMMED COMPONENT. DEPUY SYNTHES PRODUCTS USED: CATALOG NUMBER: 550000400. LOT NUMBER: 659073. COMPONENT TYPE: SHELL. UNIQUE DEVICE ID: (B)(4).

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1813308 REVERSE HUMERAL SHELL L 40+0 SHOULDER IMPLANT - HUMERAL HEAD PHX DEPUY IRELAND - 3015516266 659073 10603295546962

    Patients

    Seq Age Sex Outcome Treatment
    1 68 YR Male Required Intervention CENTRAL SCREW 6.0X35| GLENOSPHERE 36+4| LOCKING SCREW 20| LOCKING SCREW 25| LOCKING SCREW 35| MOD UNITI CONV BASEPLATE S 24| STEMLESS L 40| UNKNOWN BASEPLATE INHANCE| UNKNOWN CENTRAL SCREW INHANCE| UNKNOWN GLENOSPHERE INHANCE| UNKNOWN KICKSTAND INHANCE| UNKNOWN LOCKING SCREW INHANCE| UNKNOWN SHOULDER HUMERAL STEMS| UNKNOWN UNLOCKING SCREW INHANCE