BEUDAMED
    FDA Adverse Event Injury Summary report: N

    COMPREHENSIVE REVERSE BASEPLATE HA+ADAPTER

    MDR report key: 9306923 · Received November 11, 2019

    Report

    Report Number
    0001825034-2019-05083
    Event Type
    Injury
    Date Received
    November 11, 2019
    Date of Event
    October 16, 2018
    Report Date
    April 2, 2020
    Manufacturer
    ZIMMER BIOMET, INC.
    Product Code
    KWS
    UDI-DI
    00880304459854
    PMA / PMN Number
    K120121
    Removal / Correction Number
    N/A
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    OH, US
    Reporter Occupation
    PHYSICIAN

    Narratives

    Additional Manufacturer Narrative · 0

    (B)(4). REPORTED EVENT WAS UNABLE TO BE CONFIRMED DUE TO LIMITED INFORMATION RECEIVED FROM THE CUSTOMER. DEVICE HISTORY RECORD WAS REVIEWED AND NO DISCREPANCIES RELEVANT TO THE REPORTED EVENT WERE FOUND. 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 · 0

    NO FURTHER EVENT INFORMATION AVAILABLE AT THE TIME OF THIS REPORT.

    Additional Manufacturer Narrative · 1

    (B)(4). MEDICAL PRODUCT: CATALOG #: 115310, COMP RVRS SHLDR GLNSP STD 36MM, LOT # 341040, CATALOG #: EP-115395, E1 44-36 RTNV +3 HMRL BRG, LOT # 961540, CATALOG #: 115370, COMP RVS TRAY CO 44MM, LOT # 812250, CATALOG#: 180551, COMP LK SCREW, LOT #: 042460, CATALOG#: 180550, COMP LK SCREW, LOT #: 378700, CATALOG#: 180550, COMP LK SCREW, LOT #: 699700, CATALOG#: 115394, COMP RVS CNTRL, LOT #: 933530. THE CUSTOMER HAS NOT INDICATED WHETHER THE PRODUCT WILL BE RETURNED TO ZIMMER BIOMET FOR INVESTIGATION OR NOT. ONCE THIS INFORMATION IS OBTAINED A FOLLOW-UP MDR WILL BE SUBMITTED. 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. MULTIPLE MDR REPORTS WERE FILED FOR THIS EVENT, PLEASE SEE ASSOCIATED REPORTS: 0001825034-2019-05084, 0001825034-2019-05085, 0001825034-2019-05099. UNKNOWN.

    Description of Event or Problem · 1

    IT WAS REPORTED THAT THE PATIENT HAD AN INITIAL SURGERY APPROXIMATELY A YEAR AGO. SUBSEQUENTLY, THE PATIENT HAD A REVISION ABOUT 2 MONTHS LATER DUE TO A POST OPERATIVE INFECTION AND A 2 STAGE ANTIBIOTIC SPACER PLACEMENT. ATTEMPTS HAVE BEEN MADE AND NO FURTHER INFORMATION HAS BEEN PROVIDED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1100170 COMPREHENSIVE REVERSE BASEPLATE HA+ADAPTER PROSTHESIS, SHOULDER KWS ZIMMER BIOMET, INC. N/A 094640 00880304459854

    Patients

    Seq Age Sex Outcome Treatment
    1 Hospitalization| R SEE H10 NARRATIVE