MAUDE Adverse Event Report: INTEGRA YORK, PA INC. RUGGLES DISTRACTION SCREW STERILE 14MM; RETRACTORS

Catalog Number R6398A

Device Problem Material Integrity Problem (2978)

Patient Problem Foreign Body In Patient (2687)

Event Date 03/03/2020

Event Type  Injury  

Manufacturer Narrative

The device was not returned to the manufacturer for analysis.The plant investigation is in progress and a supplemental medwatch report will be submitted upon completion of the investigation.

Event Description

It was reported that the r6398a ruggles distraction screw sterile 14mm broke off in a patient.The patient had an anterior cervical discectomy and fusion (acdf) procedure on (b)(6) 2020.The broken distraction pin was unable to be retrieved, and the pin broke in half during removal.The piece is retained in the patient¿s cervical vertebral body.Additional information has been requested.

Manufacturer Narrative

H10.Device identifier: (b)(4), (b)(4).The product has not been received for evaluation.The issue may have been the result of normal wear or excessive force, though this could not be confirmed.Root cause could not be determined due to lack of information.Additional information received on 07apr2020 stated that a 61 year old male undergone an anterior cervical discectomy and fusion (acdf).The broken distraction pin was retained in the patient's body during the removal of the pin.Between 05nov2019 and 30jun2020, approximately 2,200 mdrs submitted electronically by integra lifesciences via trackwise, integra's complaint handling system, were not received by cdrh due to a computer system issue.Within this time period, an error with integra's middleware, which facilitates communications between trackwise and the fda system, caused the complaint records to close and indicate we had received an acknowledgement 3 from the fda when we had not.Integra interpreted the acknowledgement as a successful submission; however, subsequent investigation revealed the acknowledgement 3 received was from our middleware and not from the fda (these acknowledgements have been retained as part of the documentation of the mdr).The malfunction was related to the relocation of the trackwise application to a new data center during the transition of integra's corporate headquarters from plainsboro, nj to princeton, nj.Previously, integra had been successfully receiving acknowledgements 1, 2, and 3 from the fda, and our records reflect these acknowledgements, including the date and time stamps.Capa pr 229048 and nc 20-011 have been opened by integra to further investigate the nonconformance and develop a corrective action plan.The middleware error has been corrected, and integra has filed mdrs since the correction and verified that the appropriate acknowledgements have been received from the fda.Integra is resubmitting all impacted mdr reports for the time period 05nov2019 through 30jun2020.Integra lifesciences contacted (b)(6), director of regulatory programs, office of product evaluation and quality and (b)(6), assistant director, mdr team, office of product evaluation and quality on july 8-9, 2020 to report these issues regarding mdr reports.

• Brand Name: RUGGLES DISTRACTION SCREW STERILE 14MM
• Type of Device: RETRACTORS
• Manufacturer (Section D): INTEGRA YORK, PA INC.; 589 davies drive; 589 davies drive; york PA 17402
• MDR Report Key: 10279336
• MDR Text Key: 203157758
• Report Number: 2523190-2020-00032
• Device Sequence Number: 1
• Product Code: JXG
• Combination Product (y/n): N
• PMA/PMN Number: EXEMPT
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative,health
• Type of Report: Initial,Followup
• Report Date: 03/04/2020

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: No
• Device Operator: Health Professional
• Device Catalogue Number: R6398A
• Device Lot Number: 4140672
• Was Device Available for Evaluation?: No
• Initial Date Manufacturer Received: 03/04/2020
• Initial Date FDA Received: 07/15/2020
• Supplement Dates Manufacturer Received: 04/07/2020
• Supplement Dates FDA Received: 07/16/2020
• Is This a Reprocessed and Reused Single-Use Device?: Yes
• Patient Sequence Number: 1
• Patient Age: 61 YR