MAUDE Adverse Event Report: DEPUY SPINE INC THORACIC STRAIGHT PROBE; ORTHOPAEDIC STEREOTAXIC INSTRUMENT

Model Number	279702030N
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	10/06/2021
Type of Reportable Event	Malfunction
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.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 a spinal fusion surgery a portion of the thoracic pedicle probe broke off and remained in the patient's spinal pedicle.The surgeon used a broken instrument/screw removal tool to extract the broken piece of the probe from the patient.The broken portion of instrument was removed intact.There was a surgical delay of fifteen (15) minutes.There was no patient consequences.The procedure was successfully completed.This report is for one (1) thoracic straight probe.This is report 1 of 1 for (b)(4).

• Brand Name: THORACIC STRAIGHT PROBE
• Common Device Name: ORTHOPAEDIC STEREOTAXIC INSTRUMENT
• Manufacturer (Section D): DEPUY SPINE INC; 325 paramount drive; raynham MA 02767
• MDR Report Key: 12727824
• Report Number: 1526439-2021-02279
• Device Sequence Number: 13800029
• Product Code: OLO
• UDI-Device Identifier: 10705034388328
• UDI-Public: 10705034388328
• Combination Product (Y/N): N
• Initial Reporter State: PA
• Initial Reporter Country: US
• PMA/510(K) Number: K140927
• 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: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 10/06/2021

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: 279702030N
• Device Catalogue Number: 279702030N
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 10/06/2021
• Initial Report FDA Received Date: 11/01/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 52 YR