MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a foreign,health professional report with the FDA on 2018-08-06 for ANATOMICAL SHOULDER REVERSE, TRIAL HUMERAL CUP, 0, RETRO N/A 01.04239.600 manufactured by Zimmer Gmbh.
[116370606]
(b)(4). As no lot number was provided, the device history records could not be reviewed. Pictures and per were received and will be reviewed as part of ongoing investigation. A cause for this specific event cannot be ascertained from the information provided. As soon as supplemental information becomes available an updated report will be submitted. (b)(4).
Patient Sequence No: 1, Text Type: N, H10
[116370607]
It was reported that during the surgical procedure the item has fractured and part of it fell into the patient. The part of the fractured item has been removed from the patient. Attempts to obtain additional information have been made; however, no more is available.
Patient Sequence No: 1, Text Type: D, B5
| Report Number | 0009613350-2018-00687 |
| MDR Report Key | 7751942 |
| Report Source | FOREIGN,HEALTH PROFESSIONAL |
| Date Received | 2018-08-06 |
| Date of Report | 2018-11-13 |
| Date of Event | 2018-05-21 |
| Date Mfgr Received | 2018-11-08 |
| Device Manufacturer Date | 2017-10-16 |
| Date Added to Maude | 2018-08-06 |
| Event Key | 0 |
| Report Source Code | Manufacturer report |
| Manufacturer Link | Y |
| Number of Patients in Event | 0 |
| Adverse Event Flag | 0 |
| Product Problem Flag | 3 |
| Reprocessed and Reused Flag | 3 |
| Health Professional | 3 |
| Initial Report to FDA | 3 |
| Report to FDA | 3 |
| Event Location | 3 |
| Manufacturer Contact | MS. CHRISTINA ARNT |
| Manufacturer Street | 56 E. BELL DR. |
| Manufacturer City | WARSAW IN 46582 |
| Manufacturer Country | US |
| Manufacturer Postal | 46582 |
| Manufacturer Phone | 5745273773 |
| Manufacturer G1 | ZIMMER GMBH |
| Manufacturer Street | SULZER ALLEE 8 SULZER INDUSTRIE PARK |
| Manufacturer City | WINTERTHUR 8404 |
| Manufacturer Country | SZ |
| Manufacturer Postal Code | 8404 |
| Single Use | 3 |
| Previous Use Code | 3 |
| Removal Correction Number | N/A |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | ANATOMICAL SHOULDER REVERSE, TRIAL HUMERAL CUP, 0, RETRO |
| Product Code | HSD |
| Date Received | 2018-08-06 |
| Returned To Mfg | 2018-07-18 |
| Model Number | N/A |
| Catalog Number | 01.04239.600 |
| Lot Number | 4501867130 |
| Operator | HEALTH PROFESSIONAL |
| Device Availability | R |
| Device Age | DA |
| Device Eval'ed by Mfgr | Y |
| Device Sequence No | 0 |
| Device Event Key | 0 |
| Manufacturer | ZIMMER GMBH |
| Manufacturer Address | SULZER ALLEE 8 SULZER INDUSTRIE PARK WINTERTHUR 8404 SZ 8404 |
| Brand Name | ANATOMICAL SHOULDER REVERSE, TRIAL HUMERAL CUP, 0, RETRO |
| Product Code | MJT |
| Date Received | 2018-08-06 |
| Returned To Mfg | 2018-07-18 |
| Model Number | N/A |
| Catalog Number | 01.04239.600 |
| Lot Number | 4501867130 |
| Operator | HEALTH PROFESSIONAL |
| Device Availability | R |
| Device Age | DA |
| Device Eval'ed by Mfgr | Y |
| Device Sequence No | 1 |
| Device Event Key | 0 |
| Manufacturer | ZIMMER GMBH |
| Manufacturer Address | SULZER ALLEE 8 SULZER INDUSTRIE PARK WINTERTHUR 8404 SZ 8404 |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 2018-08-06 |