MAUDE Adverse Event Report: WRIGHTS LANE SYNTHES USA PRODUCTS LLC 12MM / TI CANN FRN / GT 400MM / RIGHT - STERILE; ROD,FIXATION,INTRAMEDULLARY

Model Number	04.033.270S
Medical Device Problem Code	Device-Device Incompatibility (2919)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	09/20/2021
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
(b)(4).Complainant part is not expected to be returned for manufacturer review/ investigation.The investigation could not be completed, no product was received; no conclusion could be drawn at the time of filing this report.The 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 history lot, part: 04.033.270s-us, lot: l984217, manufacturing site: (b)(4), release to warehouse date: 13 august 2018, expiration date: 31 july 2028.A manufacturing record evaluation was performed for the finished article lot and no non-conformances were identified.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 for a surgery.During the surgery, while attempting to insert recon screws into an unknown femoral recon nail (frn), the surgeon hit the nail with the drill bit.The nail was unstable because the surgeon did not pin both trocars before removing guide wire to drill the first hole.There was no surgical delay.The procedure was successfully completed.There was no patient consequence reported.This complaint involves an unknown number of devices.This report is for (1) 12mm / ti cann frn / gt 400mm / right - sterile.This report is 1 of 10 of (b)(4).

• Brand Name: 12MM / TI CANN FRN / GT 400MM / RIGHT - STERILE
• Common Device Name: ROD,FIXATION,INTRAMEDULLARY
• Manufacturer (Section D): WRIGHTS LANE SYNTHES USA PRODUCTS LLC; 1302 wrights lane east; west chester PA 19380
• MDR Report Key: 12641953
• Report Number: 2939274-2021-06131
• Device Sequence Number: 11616288
• Product Code: HSB
• UDI-Device Identifier: 10886982271815
• UDI-Public: (01)10886982271815
• Combination Product (Y/N): N
• Initial Reporter State: TX
• Initial Reporter Country: US
• PMA/510(K) Number: K172157
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 09/20/2021

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: 04.033.270S
• Device Catalogue Number: 04.033.270S
• Device Lot Number: L984217
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 09/20/2021
• Initial Report FDA Received Date: 10/15/2021
• Patient Sequence Number: 1
• Patient Age: 47 YR
• Patient Weight: 87