BEUDAMED
    FDA Adverse Event Injury Summary report: N

    COMP RVRS 25MM BSPLT HA+ADPTR

    MDR report key: 7286033 · Received February 21, 2018

    Report

    Report Number
    0001825034-2018-00974
    Event Type
    Injury
    Date Received
    February 21, 2018
    Report Date
    April 3, 2018
    Manufacturer
    ZIMMER BIOMET, INC.
    Product Code
    KWS
    PMA / PMN Number
    PK120121
    Removal / Correction Number
    N/A
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    IL, US
    Reporter Occupation
    PHYSICIAN

    Narratives

    Additional Manufacturer Narrative · 1

    (B)(4). CONCOMITANT MEDICAL PRODUCTS: 115397, COMP RVS CNTRL 6.5X35MM ST/RST, 938510, 180555, COMP LK SCR 3.5HEX 4.75X40 ST, 350220, 180553, COMP LK SCR 3.5HEX 4.75X30 ST, 770260, 180550, COMP LK SCR 3.5HEX 4.75X15 ST, 541550, 180552, COMP LK SCR 3.5HEX 4.75X25 ST, 593070, 180553, COMP LK SCR 3.5HEX 4.75X30 ST, 800380, 115310, COMP RVRS SHLDR GLNSP STD 36MM, 670960. CUSTOMER HAS INDICATED THAT THE PRODUCT WILL NOT BE RETURNED TO ZIMMER BIOMET FOR INVESTIGATION. THE INVESTIGATION IS IN PROCESS. ONCE THE INVESTIGATION HAS BEEN COMPLETED, A FOLLOW-UP MDR WILL BE SUBMITTED. MULTIPLE MDR REPORTS WERE FILED FOR THIS EVENT, PLEASE SEE ASSOCIATED REPORTS: 0001825034 - 2018 - 00973, 0001825034 - 2018 - 01157, 0001825034 - 2018 - 01158, 0001825034 - 2018 - 01159, 0001825034 - 2018 - 01160, 0001825034 - 2018 - 01161 , 0001825034 - 2018 - 01162. DISCARDED.

    Additional Manufacturer Narrative · 1

    THIS FOLLOW-UP REPORT IS BEING SUBMITTED TO RELAY ADDITIONAL INFORMATION. CONCOMITANT MEDICAL DEVICES: UNK STEM, UNK BEARING, UNK TRAY, 118000 25MM VERSA-DIAL TAPER ADAPTOR 925230. REPORTED EVENT WAS UNABLE TO BE CONFIRMED DUE TO LIMITED INFORMATION RECEIVED FROM THE CUSTOMER. DHR WAS REVIEWED AND NO DISCREPANCIES WERE FOUND. REVIEW OF THE COMPLAINT HISTORY DETERMINED THAT NO FURTHER ACTION IS REQUIRED ROOT CAUSE WAS UNABLE TO BE DETERMINED AS THE NECESSARY INFORMATION TO ADEQUATELY INVESTIGATE THE REPORTED EVENT WAS NOT PROVIDED. IF ANY FURTHER INFORMATION IS FOUND WHICH WOULD CHANGE OR ALTER ANY CONCLUSIONS OR INFORMATION, A SUPPLEMENTAL WILL BE FILED ACCORDINGLY. ZIMMER BIOMET WILL CONTINUE TO MONITOR FOR TRENDS.

    Description of Event or Problem · 1

    IT WAS REPORTED THAT PATIENT WAS REVISED DUE TO PAIN AND DISASSOCIATION. AFTER THE REVISION SURGERY PATIENT IS EXPERIENCING LIMITED RANGE OF MOTION. ATTEMPTS HAVE BEEN MADE AND ADDITIONAL INFORMATION ON THE REPORTED EVENT IS UNAVAILABLE.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    129044 COMP RVRS 25MM BSPLT HA+ADPTR PROSTHESIS, SHOULDER KWS ZIMMER BIOMET, INC. N/A 951230

    Patients

    Seq Age Sex Outcome Treatment
    1 Hospitalization| O| R