BEUDAMED
    FDA Adverse Event Injury Summary report: N

    DEPUY SHOULDER SYSTEM

    MDR report key: 7095600 · Received December 6, 2017

    Report

    Report Number
    MW5073799
    Event Type
    Injury
    Date Received
    December 6, 2017
    Date of Event
    November 5, 1909
    Report Date
    November 28, 2017
    Manufacturer
    DEPUY ORTHOPAEDICS INC.
    Product Code
    KWS
    Adverse Event
    Yes
    Report Source
    Voluntary report
    Reporter Location
    ME, US
    Reporter Occupation
    OTHER

    Narratives

    Description of Event or Problem · 1

    MY ORIGINAL SHOULDER KEEPS GOING OUT. THEY PUT A NEW ONE IN AND IT STILL DOES THE SAME THING, ONLY WORSE. IT GOES OUT 3 OR 4 TIMES A DAY. IF I HAD SURGERY ON IT 50/50 I WILL LOSE USAGE. REF # 1136-42-026 LOT # DP5MWA000 CROSSWALK ANCHOR SEG GLENOID. REF # 1128-48-110 LOT # C4HCI1000 SHOULDER ELECTRIC HEAD, REF # 1137-12-000, LOT # C44DCC000 STEM.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    865869 DEPUY SHOULDER SYSTEM DEPUY SHOULDER SYSTEM KWS DEPUY ORTHOPAEDICS INC.

    Patients

    Seq Age Sex Outcome Treatment
    1 58 YR