MAUDE Adverse Event Report: WRIGHTS LANE SYNTHES USA PRODUCTS LLC 4.5 VACRVD CONDY PL/18H/370/RT; IMPLANT,FIXATION DEVICE, CONDYLAR PLATE

Model Number	02.124.418
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	Nonunion/Delayed-union Bone Fracture (2369)
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Additional procode: hrs, hwc.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.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
Device report from synthes reports an event in (b)(6) as follows: it was reported that on an unknown date, one (1) unknown screw and one (1) 4.5mm va-lcp curved condylar plate broke in the patient.The patient experienced non-union and required revision surgery.The original date of surgery is unknown.There is no further information available.This report is for one (1) 4.5mm va-lcp curved condylar plate/18 hole/370mm/right.This is report 2 of 2 for (b)(4).

• Brand Name: 4.5 VACRVD CONDY PL/18H/370/RT
• Common Device Name: IMPLANT,FIXATION DEVICE, CONDYLAR PLATE
• Manufacturer (Section D): WRIGHTS LANE SYNTHES USA PRODUCTS LLC; 1302 wrights lane east; west chester PA 19380
• MDR Report Key: 11807084
• Report Number: 2939274-2021-02309
• Device Sequence Number: 17019062
• Product Code: JDP
• UDI-Device Identifier: 10886982042972
• UDI-Public: 10886982042972
• Combination Product (Y/N): N
• Initial Reporter Country: CA
• PMA/510(K) Number: K110354
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 04/16/2021

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: 02.124.418
• Device Catalogue Number: 02.124.418
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 04/16/2021
• Initial Report FDA Received Date: 05/11/2021
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention