MAUDE Adverse Event Report: WRIGHTS LANE SYNTHES USA PRODUCTS LLC 3.5MM LOCKING ATTACHMENT PLATE FOR 4.5MM LCP PLATE/4 HOLES; PLATE, FIXATION, BONE

Model Number	02.120.601
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
Complainant part is not expected to be returned for manufacturer review/investigation.(b)(4).The investigation could not be completed; no conclusion could be drawn, as no product was received.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
It was reported that on (b)(6) 2021 the patient underwent hardware removal of a right femur for osteomyelitis infection.The original date of surgery was (b)(6) 2019.All hardware was removed easily.There was (1) postoperatively broken screw.No fragments were generated from the broken implant.There was no surgical delay reported.No further information provided.This report is for (1) 3.5mm locking attachment plate for 4.5mm lcp plate/4 holes.This is report 8 of 15 for complaint (b)(4).
Additional Manufacturer Narrative
Depuy synthes is submitting this report pursuant to the provisions of 21 cfr, part 803.This report may be based on information which depuy synthes has not been able to investigate or verify prior to the required reporting date.This report does not reflect a conclusion by fda, depuy synthes or its employees that the report constitutes an admission that the device, depuy synthes, or its employees caused or contributed to the potential event described in this report.If the information is unknown, not available or does not apply, the section/field of the form is left blank.H10 additional narrative: h3, h4, h6: part # 02.201.601.Lot # l794150 expiration date: february 1, 2028 release to warehouse date: march 9, 2018 manufacturer: raron no ncr's were generated during production.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.

• Brand Name: 3.5MM LOCKING ATTACHMENT PLATE FOR 4.5MM LCP PLATE/4 HOLES
• 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: 12088796
• Report Number: 2939274-2021-03321
• Device Sequence Number: 3323540
• Product Code: HRS
• UDI-Device Identifier: 10886982040084
• UDI-Public: (01)10886982040084
• Combination Product (Y/N): N
• Initial Reporter State: NV
• Initial Reporter Country: US
• PMA/510(K) Number: K083573
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2019
• Device Explanted Year: 2021
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 06/07/2021

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: 02.120.601
• Device Catalogue Number: 02.120.601
• Device Lot Number: L794150
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 06/07/2021
• Supplement Date Received by Manufacturer: 08/06/2021
• Initial Report FDA Received Date: 06/29/2021
• Supplement Report FDA Received Date: 08/06/2021
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: 2.7MM CORTEX SCREW SELF-TAPPING 30MM; 2.7MM CORTEX SCREW SELF-TAPPING 30MM; 2.7MM CORTEX SCREW SELF-TAPPING 30MM; 2.7MM CORTEX SCREW SELF-TAPPING 30MM; 3.5 LCKNG ATTACH PL FOR 4.5 LCP PL/4 H; 4.5 CURVED BROAD LCP PL 12 HOLES/229; 4.5MM CORTEX SCREW SELF-TAPPING 38MM; 4.5MM CORTEX SCREW SELF-TAPPING 40MM; 4.5MM CORTEX SCREW SELF-TAPPING 40MM; 4.5MM CORTEX SCREW SELF-TAPPING 50MM; 5.0 TI LCKNG SCR T25 SD 50 FOR IM NAILS; 9/125 DEG TI CANN TFNA 400/RIGHT - SILE; TFNA FENESTRATED SCREW 90MM - STERILE; UNK-TI LOCKING SCREW
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Weight: 109