MAUDE Adverse Event Report: GLOBUS MEDICAL, INC. REVERE; 5.5MM CLOSED OFFSET CONNECTOR, 5.5MM ROD, 30MM

Model Number	124.993
Health Effect - Clinical Code	Insufficient Information (4580)
Date of Event	04/04/2019
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The imaging provided showed the implant with normal wear and tear.However, the exact cause of the reported issue could not be determined.
Event or Problem Description
It was reported that a revision surgery was done to remove and replace a revere rod that broke 5 years post operatively.

• Brand Name: REVERE
• Common Device Name: 5.5MM CLOSED OFFSET CONNECTOR, 5.5MM ROD, 30MM
• Manufacturer (Section D): GLOBUS MEDICAL, INC.; 2560 general armistead avenue; audubon 19403
• MDR Report Key: 12270443
• Report Number: 3004142400-2021-00127
• Device Sequence Number: 19946987
• Product Code: MNH
• UDI-Device Identifier: 00849044003048
• UDI-Public: 00849044003048
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: E568761
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Explanted Year: 2019
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 07/27/2021

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: 124.993
• Device Lot Number: VPL214DC
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 07/07/2021
• Initial Report FDA Received Date: 08/03/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Other