MAUDE Adverse Event Report: WRIGHTS LANE SYNTHES USA PRODUCTS LLC 5.5 TI HD PRECON ROD 80MM STR LEN/400MM; ORTHOSIS, SPONDYLOLISTHESIS SPINAL FIXATION

Model Number	04.633.280
Medical Device Problem Code	Material Integrity Problem (2978)
Health Effect - Clinical Code	Appropriate Clinical Signs, Symptoms and Conditions Term/Code Not Available (4581)
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Additional narrative: additional product code: nkb, mni, kwq, kwp.Complainant part is not expected to be returned for manufacturer review/investigation.(b)(4).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.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, patient underwent a hardware removal due to broken rods.The patient had bilateral broken rods and had to have them replaced.It was found when the patient came to the doctor's office for the post-op follow up.This report is for one (1) 5.5mm ti hard precontoured rod 80mm straight length/400mm.This is report 2 of 2 for complaint (b)(4).

• Brand Name: 5.5 TI HD PRECON ROD 80MM STR LEN/400MM
• Common Device Name: ORTHOSIS, SPONDYLOLISTHESIS SPINAL FIXATION
• Manufacturer (Section D): WRIGHTS LANE SYNTHES USA PRODUCTS LLC; 1302 wrights lane east; west chester PA 19380
• MDR Report Key: 12422948
• Report Number: 2939274-2021-05184
• Device Sequence Number: 11665053
• Product Code: MNH
• UDI-Device Identifier: 10705034746449
• UDI-Public: (01)10705034746449
• Combination Product (Y/N): N
• Initial Reporter State: FL
• Initial Reporter Country: US
• PMA/510(K) Number: EXEMPT
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 08/07/2021

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?: Yes
• Operator of Device: Health Professional
• Device Model Number: 04.633.280
• Device Catalogue Number: 04.633.280
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 08/07/2021
• Initial Report FDA Received Date: 09/03/2021
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: 5.5 TI HD PRECON ROD 80MM STR LEN/400MM; UNK - MONO/POLYAXIAL SCREWS: MATRIX
• Outcome Attributed to Adverse Event: Required Intervention