MAUDE Adverse Event Report: WRIGHTS LANE SYNTHES USA PRODUCTS LLC 3.5 LCP PERIARTIC PRX HUM PL 5H/145/LT-S; PLATE,FIXATION,BONE

Model Number	02.123.043S
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Appropriate Clinical Signs, Symptoms and Conditions Term/Code Not Available (4581)
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Product complaint # (b)(4).Complainant part is not expected to be returned for manufacturer review/ investigation.Reporter is a j&j sales representative.Without a lot number, the device history records review could not be completed as no product was received.The investigation could not be completed, no conclusion could be drawn at the time of filing this report.The product was not returned.Based on the information available, it has been determined that no corrective and 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
It was reported that on an unknown date after sterilization, it was discovered that there were devices that had an unknown allegation.There was no patient involvement.This complaint involves thirteen (13) devices.This report is for (1) 3.5mm lcp periartic prox hum plate 5h/145mm/rt-sterile.This report is 2 of 13 for (b)(4).

• Brand Name: 3.5 LCP PERIARTIC PRX HUM PL 5H/145/LT-S
• Common Device Name: PLATE,FIXATION,BONE
• Manufacturer (Section D): WRIGHTS LANE SYNTHES USA PRODUCTS LLC; 1302 wrights lane east; west chester PA 19380
• MDR Report Key: 12017862
• Report Number: 2939274-2021-03009
• Device Sequence Number: 11826365
• Product Code: HRS
• UDI-Device Identifier: 10886982042385
• UDI-Public: (01)10886982042385
• Combination Product (Y/N): N
• Initial Reporter State: MO
• Initial Reporter Country: US
• PMA/510(K) Number: K082625
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 05/25/2021

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?: No
• Operator of Device: Health Professional
• Device Model Number: 02.123.043S
• Device Catalogue Number: 02.123.043S
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 05/25/2021
• Initial Report FDA Received Date: 06/17/2021
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: 2.7 MM VA-LCP LAT DIS FIB 5H R; 5.0 VAL SCREOPTILINK SLF-TPNG/SD/95-S; LCP PROX-HUM-PL-3.5 PERIARTICULAR LE 5HO; LCP PROX-HUM-PL-3.5 PERIARTICULAR R 5HO; LCP PROX-HUM-PL-3.5 PERIARTICULAR R 6HO; LCP PROX-HUM-PL-3.5 PERIARTICULAR R 8HO; SPRING PL 3.5 2HO L31.5 SST
• Outcome Attributed to Adverse Event: Required Intervention