MAUDE Adverse Event Report: STRYKER GMBH DISTAL POSTERIOR LATERAL HUMERUS PLATE VARIAX FOR RIGHT HUMERUS 3 HOLE / L81M; PLATE, FIXATION, BONE

Model Number	629263
Medical Device Problem Code	Positioning Failure (1158)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	09/08/2020
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Device will not be returned.If additional information becomes available, it will be provided in a supplemental report.
Event or Problem Description
It was reported, primary humeral plating procedure.It was reported that the locking screw would not lock into the plate.The screw was removed and a second locking screw was used, which also wouldn't lock into the plate.The screw was removed and the surgeon decided the plate had sufficient fixation.Patient was closed and procedure was completed successfully with a delay of less than 5 minutes.The rep confirmed that no further information is available.

• Brand Name: DISTAL POSTERIOR LATERAL HUMERUS PLATE VARIAX FOR RIGHT HUMERUS 3 HOLE / L81M
• Common Device Name: PLATE, FIXATION, BONE
• Manufacturer (Section D): STRYKER GMBH; bohnackerweg 1; postfach; selzach 2545 ; SZ 2545
• MDR Report Key: 10603315
• Report Number: 0008031020-2020-02280
• Device Sequence Number: 3620069
• Product Code: HRS
• UDI-Device Identifier: 07613327082890
• UDI-Public: 07613327082890
• Combination Product (Y/N): N
• Initial Reporter State: WA
• Initial Reporter Country: US
• PMA/510(K) Number: K141677
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 09/29/2020

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?: Yes
• Operator of Device: Health Professional
• Device Model Number: 629263
• Device Catalogue Number: 629263
• Device Lot Number: UNKNOWN
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 09/08/2020
• Initial Report FDA Received Date: 09/29/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1