MAUDE Adverse Event Report: MEDOS INTERNATIONAL SÃ RL CH MINI POLYAXIAL BONE SCREW 3.5 X 3.5 X 14MM; ORTHOSIS, CERVICAL PEDICLE SCREW SPINAL FIXATION

Model Number	188318314
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.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
Device report from (b)(6) reports an event as follows: it was reported that on (b)(6) 2018 the primary posterior fusion at c3/4 was performed.On (b)(6) 2021 a revision procedure (depression and c3-c6 extension) was performed to treat an adjacent disorder.The surgeon confirmed that any product defectiveness was not the cause of the revision procedure.This report is for one (1) mini polyaxial bone screw 3.5 x 3.5 x 14mm.This is report 3 of 3 for (b)(4).

• Brand Name: MINI POLYAXIAL BONE SCREW 3.5 X 3.5 X 14MM
• Common Device Name: ORTHOSIS, CERVICAL PEDICLE SCREW SPINAL FIXATION
• Manufacturer (Section D): MEDOS INTERNATIONAL SÃ RL CH; chemin-blanc 38; le locle 02400 ; SZ 02400
• MDR Report Key: 12203906
• Report Number: 1526439-2021-01447
• Device Sequence Number: 14717874
• Product Code: NKG
• UDI-Device Identifier: 10705034157184
• UDI-Public: 10705034157184
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: K041203
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2018
• Device Explanted Year: 2021
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 06/22/2021

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: 188318314
• Device Catalogue Number: 188318314
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 06/22/2021
• Initial Report FDA Received Date: 07/21/2021
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: 3.5 ROD 60MM; MNTR F/A SCREW 3.5X12; UNK - SCREW/ROD CONSTRUCT ACCESSORIES
• Outcome Attributed to Adverse Event: Required Intervention