MAUDE Adverse Event Report: WRIGHTS LANE SYNTHES USA PRODUCTS LLC TFNA FENESTRATED HELICAL BLADE 85MM - STERILE; ROD, FIXATION, INTRAMEDULLARY

Model Number	04.038.385S
Medical Device Problem Code	Migration (4003)
Health Effect - Clinical Codes	Nonunion/Delayed-union Bone Fracture (2369); No Code Available (3191)
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Product complaint # (b)(4).Complainant part is not expected to be returned for manufacturer review/investigation.A review of the device history record has been requested.The investigation could not be completed; no conclusion could be drawn at the time of filing this report.Device was used for treatment, not diagnosis.If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.
Event or Problem Description
It was reported that on (b)(6) 2020, the surgeon statically locked the trochanteric fixation nail advanced (tfna) fenestrated helical blade 85mm sterile.Post-operative follow-up films show that the helical blade has collapsed and the patient has lost some reduction causing a delayed union.It is unknown if the procedure was completed successfully.It is unknown if there was a surgical delay.Patient outcome was unknown.This (b)(4) pertains to case 1 and complaint is reference to the this (b)(4) for the other case.Concomitant device reported: 11mm/130 deg titanium cannulated trochanteric fixation nail advanced (tfna) 420mm/right - sterile (part# 04.037.162s; lot# h234696, quantity 1).This complaint involves one (1) device.This report is 1 of 1 for (b)(4).
Additional Manufacturer Narrative
Depuy synthes is submitting this report pursuant to the provisions of 21 cfr, part 803.This report may be based on information which depuy synthes has not been able to investigate or verify prior to the required reporting date.This report does not reflect a conclusion by fda, depuy synthes or its employees that the report constitutes an admission that the device, depuy synthes, or its employees caused or contributed to the potential event described in this report.H6: code 3191 used to capture surgical intervention, medical device removal and loss of anatomical alignment after fracture reduction.H3, h4, h6: manufacturing location: elmira / packaged, sterilized and released by: monument, manufacturing date: 13-nov-2019, expiration date: 30-sep-2029, part number: 04.038.385s, tfna fenestrated helical blade 85mm -sterile, lot number: 25p1010 (sterile), lot quantity: (b)(4).Note: helical blade was manufactured by elmira; lot number 22p7948.Parts were packaged, sterilized and released by monument.Production order traveler met all inspection acceptance criteria.Packaging label log (pll) was reviewed and determined to be conforming.Packaging bom was reviewed and determined to be conforming with no deviations to normal packaging identified.Scn 16849 supplied by sterigenics was reviewed and determined to be conforming.This lot met all visual, sterility and packaging criteria at the time of release with no issues documented during the manufacture that would contribute to this complaint condition.Product was not returned.Based on the information available, it has been determined that no corrective and/or preventative action is proposed.This complaint will be accounted for and monitored via post market surveillance activities.If additional information is made available, the investigation will be updated as applicable.Device was used for treatment, not diagnosis.If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.

• Brand Name: TFNA FENESTRATED HELICAL BLADE 85MM - STERILE
• Common Device Name: ROD, FIXATION, INTRAMEDULLARY
• Manufacturer (Section D): WRIGHTS LANE SYNTHES USA PRODUCTS LLC; 1302 wrights lane east; west chester PA 19380
• MDR Report Key: 10135744
• Report Number: 2939274-2020-02751
• Device Sequence Number: 16939881
• Product Code: HSB
• UDI-Device Identifier: 10886982099235
• UDI-Public: (01)10886982099235
• Combination Product (Y/N): N
• Initial Reporter State: CO
• PMA/510(K) Number: K160167
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2020
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 05/28/2020

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Model Number: 04.038.385S
• Device Catalogue Number: 04.038.385S
• Device Lot Number: 25P1010
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 05/28/2020
• Supplement Date Received by Manufacturer: 06/23/2020
• Initial Report FDA Received Date: 06/09/2020
• Supplement Report FDA Received Date: 07/02/2020
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: 11MM/130 DEG TI CANN TFNA 420MM/RIGHT - STERILE.; TFNA FENESTRATED HELICAL BLADE 85MM - STERILE.
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Weight: 81