MAUDE Adverse Event Report: WRIGHTS LANE SYNTHES USA PRODUCTS LLC 3.5MM CRTX SCREW/LOW PROF HD SELF-TAPPING/STRDRV/16MM-STER; SCREW, FIXATION, BONE

Model Number	02.206.216
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Nonunion/Delayed-union Bone Fracture (2369); No Code Available (3191)
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Complainant part is not expected to be returned for manufacturer review/investigation.Without a lot number the device history records review could not be completed.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.(b)(4).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, nonunion occurred and 6 hole va-lcp medial distal plate with six 2.7mm va locking screws, three 3.5 cortical screws, one 3.5 locking screw were all removed and one unknown broken 2.7mm va locking screw that was left in the distal portion of the tibia.It is unknown if there was a surgical delay reported.The procedure and patient outcomes were unknown.This report is for one (1) 3.5mm crtx screw/low prof hd self-tapping/strdrv/16mm-ster.This is report 1 of 2 for (b)(4).This report is linked to (b)(4).

• Brand Name: 3.5MM CRTX SCREW/LOW PROF HD SELF-TAPPING/STRDRV/16MM-STER
• Common Device Name: SCREW, FIXATION, BONE
• Manufacturer (Section D): WRIGHTS LANE SYNTHES USA PRODUCTS LLC; 1302 wrights lane east; west chester PA 19380
• MDR Report Key: 10816713
• Report Number: 2939274-2020-05055
• Device Sequence Number: 1114291
• Product Code: HWC
• UDI-Device Identifier: 10886982050946
• UDI-Public: 10886982050946
• Combination Product (Y/N): N
• Initial Reporter State: WI
• Initial Reporter Country: US
• PMA/510(K) Number: K111230
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Explanted Year: 2020
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 10/15/2020

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?: No
• Operator of Device: Health Professional
• Device Model Number: 02.206.216
• Device Catalogue Number: 02.206.216TS
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 10/15/2020
• Initial Report FDA Received Date: 11/10/2020
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention