MAUDE Adverse Event Report: DEPUY SPINE INC 5.5 EXP VERSE FEN SCR 7.0X35; APPLIANCE, FIXATION, SPINAL INTERVERTEBRAL BODY

Model Number	199723735S
Medical Device Problem Code	Migration (4003)
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 device product codes: nkb; kwp.D9: 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
Device report from synthes reports an event in (b)(6) as follows: it was reported that on (b)(6) 2021, the fusion procedure (th11-l4) was performed with the verse fenestrated screw and the verse prime system.The procedure was completed without any issue.On an unknown postoperative date, it was found that the verse fenestrated screw had backed out.No further information is available.This report is for one (1) expedium verse spine system fenestrated cortical fix polyaxial screw 7.0 x 35mm.This is report 1 of 1 for complaint (b)(4).

• Brand Name: 5.5 EXP VERSE FEN SCR 7.0X35
• Common Device Name: APPLIANCE, FIXATION, SPINAL INTERVERTEBRAL BODY
• Manufacturer (Section D): DEPUY SPINE INC; 325 paramount drive; raynham MA 02767
• MDR Report Key: 12748560
• Report Number: 1526439-2021-02314
• Device Sequence Number: 4489683
• Product Code: KWQ
• UDI-Device Identifier: 10705034444529
• UDI-Public: (01)10705034444529
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: K173095
• 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,foreig
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 10/08/2021

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: 199723735S
• Device Catalogue Number: 199723735S
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 10/08/2021
• Initial Report FDA Received Date: 11/03/2021
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention