MAUDE Adverse Event Report: SMITH & NEPHEW, INC. PERI-LOC 4.5MM T25 TI LCK SCR 66MM S-T; PLATE, FIXATION, BONE

Model Number	71867066
Medical Device Problem Code	Connection Problem (2900)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	06/14/2021
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that, during a trauma surgery while the instrument was inside of the patient, the screw was not locked and penetrated the hole on the plate.The peri-loc 4.5mm ti l-d fem pl 8h l 193mm, peri-loc 4.5mm t25 ti lck scr 66mm s-t, two (2) peri-loc 4.5mm t25 ti lck scr 64mm s-t and peri-loc 4.5mm t25 ti lck scr 58mm s-t; it was unknown if the plate or which screws reported were defective.The procedure was successfully completed putting back and rotating in an opposite direction without delay using the same device.Patient was not harmed.
Additional Manufacturer Narrative
H3, h6: the device, used in treatment, was not returned for evaluation and the reported event could not be confirmed.A review of the manufacturing records did not reveal a manufacturing abnormality that could have caused or contributed to the reported incident.A review of complaint history did not reveal additional complaints for the listed batch.At this time, we have no reason to suspect that the product failed to meet any product specifications at the time of manufacture.Some potential probable causes for this event could include a fit/ sizing issue or poor insertion technique.Based on this investigation, the need for corrective action is not indicated.Without the return of the actual product involved, our investigation could not proceed.Should the device or additional information be received, the complaint will be reopened.No further investigation is warranted for this complaint; however, we will continue to monitor for future complaints and investigate as necessary.We consider this investigation closed.

• Brand Name: PERI-LOC 4.5MM T25 TI LCK SCR 66MM S-T
• Common Device Name: PLATE, FIXATION, BONE
• Manufacturer (Section D): SMITH & NEPHEW, INC.; 1450 brooks rd.; memphis TN 38116
• MDR Report Key: 12082287
• Report Number: 1020279-2021-05483
• Device Sequence Number: 3464985
• Product Code: HRS
• UDI-Device Identifier: 03596010641694
• UDI-Public: 03596010641694
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: K083032
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 08/06/2021

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: 71867066
• Device Catalogue Number: 71867066
• Device Lot Number: 20GT40101
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 06/15/2021
• Supplement Date Received by Manufacturer: 08/05/2021
• Initial Report FDA Received Date: 06/29/2021
• Supplement Report FDA Received Date: 08/06/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1