MAUDE Adverse Event Report: WRIGHTS LANE SYNTHES USA PRODUCTS LLC MATRIXWAVE F TI 1.85 SCR SELF-DRL/8 LNTH; PLATE, BONE

Model Number	04.503.825.01
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	10/04/2021
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Without a lot number the device history records review could not be completed.Product was not returned.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, during an unknown procedure, the screw broke off in the patients mandible.There was no surgical delay.The procedure was successfully completed.Patient outcome is unknown.This report is for (1) matrixwave f ti 1.85 scr self-drl/8 lnth.This is report 2 of 2 for (b)(4).

• Brand Name: MATRIXWAVE F TI 1.85 SCR SELF-DRL/8 LNTH
• Common Device Name: PLATE, BONE
• Manufacturer (Section D): WRIGHTS LANE SYNTHES USA PRODUCTS LLC; 1302 wrights lane east; west chester PA 19380
• MDR Report Key: 12712850
• Report Number: 2939274-2021-06368
• Device Sequence Number: 4560805
• Product Code: JEY
• UDI-Device Identifier: 10887587069487
• UDI-Public: (01)10887587069487
• Combination Product (Y/N): N
• Initial Reporter State: MI
• Initial Reporter Country: US
• PMA/510(K) Number: K141165
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2021
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 10/04/2021

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: 04.503.825.01
• Device Catalogue Number: 04.503.825.01
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 10/04/2021
• Initial Report FDA Received Date: 10/28/2021
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: MATRIXWAVE F TI 1.85 SCR SELF-DRL/8 LNTH
• Patient Age: 38 YR