MAUDE Adverse Event Report: STRYKER GMBH PROXIMAL LATERAL HUMERUS PLATE AXSOS 3 TI FOR RIGHT HUMERUS 3 HOLE / L86MM; PLATE, FIXATION, BONE

Model Number	627233S
Medical Device Problem Code	Positioning Failure (1158)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	10/02/2020
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; device remains implanted in patient.
Event or Problem Description
As reported, "the third row from the proximal position, but it did not lock, and i reinserted another locking screw, but it did not lock.After all, the screw was inserted without locking.Other screw holes are fine.".
Event or Problem Description
As reported: "the third row from the proximal position, but it did not lock and i reinserted another locking screw, but it did not lock.After all, the screw was inserted without locking.Other screw holes are fine.".
Additional Manufacturer Narrative
The reported event could not be confirmed, since the device was not returned for evaluation and no other evidences were provided.More detailed information about the complaint event as well as the affected device must be available in order to determine the root cause of the complaint event.A review of the device history for the reported lot did not indicate any abnormalities.No corrective actions are required at this time.A review of the labeling did not indicate any abnormalities.No indications of material, manufacturing or design related problems were found during the investigation.If the device is returned or if any additional information is provided, the investigation will be reassessed.

• Brand Name: PROXIMAL LATERAL HUMERUS PLATE AXSOS 3 TI FOR RIGHT HUMERUS 3 HOLE / L86MM
• Common Device Name: PLATE, FIXATION, BONE
• Manufacturer (Section D): STRYKER GMBH; bohnackerweg 1; postfach; selzach 2545 ; SZ 2545
• MDR Report Key: 10748749
• Report Number: 0008031020-2020-02358
• Device Sequence Number: 3060513
• Product Code: HRS
• UDI-Device Identifier: 07613327091243
• UDI-Public: 07613327091243
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: K200398
• 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,Followup
• Report Date (Section B): 12/22/2020

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 Expiration Date: 04/30/2025
• Device Model Number: 627233S
• Device Catalogue Number: 627233S
• Device Lot Number: G25942
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 10/02/2020
• Supplement Date Received by Manufacturer: 11/26/2020
• Initial Report FDA Received Date: 10/28/2020
• Supplement Report FDA Received Date: 12/22/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1