Product was received by manufacturer.Visual examination was performed.The review of the device history records and traceability did not reveal any non-conformances to specifications or deviations in procedures that might have contributed to the reported event.One of the two screws actually moved during the initial surgery.The surgeon felt it, but thought that adding the cage and the anchoring plate would allow the overall stability.The screw has not migrated, but seems not "hooked" during the revision.As a result, compression should not be very effective.The cage also seemed to move during the revision.No fusion or fibrosis present during the revision.During the revision, the surgeon did not use the anchoring plate avenue t unlocking system but managed to remove the 2 half-anchoring plates with the hook.Therefore, it is possible to say that these 2 half anchoring plates were probably not locked in the cage.Investigation found that root cause of this event is an use error during anchoring plate insertion.Causing conflict with the easyspine screw and preventing the proper locking of the 2 half anchoring plate.Indeed, during the binocular analysis of the half anchoring plate, marks were found on the tip of one half anchoring plate.The tip were twisted / blunted.As mentioned in the surgical technique ": if a posterior osteosynthesis system is inserted, anchoring plate insertion must be done with care to avoid any conflict between both constructs.Investigation found no evidence to a product issue.Root cause of the event : user error ( failure to follow instruction during plate insertion).
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