MAUDE Adverse Event Report: TREACE MEDICAL CONCEPTS, INC. THREADED PLATE TACK GEN 2.5; OLIVE WIRE

Model Number	1405-2579
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	Foreign Body In Patient (2687)
Date of Event	10/26/2022
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
It was reported that the tip of a threaded plate tack broke off and was retained in the patient's bone during a bunion procedure on (b)(6) 2022.The case was completed successfully with no additional patient outcomes.The device was returned for evaluation and analysis confirmed the plate tack broke in the middle of the threads.The olive wire is provided to customers within a sterile kit (sn22) and marked single use.The udi referenced is for the sterile kit, sn22, the product is distributed within.The device history records were reviewed for all possible lots and no issues were identified that could have contributed to what was reported.Based on the analysis and available information, it is likely the technique utilized applied additional forces or bending stresses to the device or it broke due to impact with another device.Although the company has determined that the subject event in this mdr is unlikely to result in a serious injury if it recurred, the company has decided to file the mdr in an abundance of caution and to ensure full compliance with 21 cfr part 803.The company will supplement this mdr as necessary and appropriate.
Event or Problem Description
It was reported that the tip of a threaded plate tack broke off and was retained in the patient's bone during a bunion procedure on (b)(6) 2022.The case was completed successfully with no additional patient outcomes.

• Brand Name: THREADED PLATE TACK GEN 2.5
• Common Device Name: OLIVE WIRE
• Manufacturer (Section D): TREACE MEDICAL CONCEPTS, INC.; 100 palmetto park place; ponte vedra FL 32081
• Manufacturer (Section G): TREACE MEDICAL CONCEPTS, INC.; 100 palmetto park place; ponte vedra FL 32081
• Manufacturer Contact: uriza shums ; 100 palmetto park place; ponte vedra, FL 32081 ; 9043735940
• MDR Report Key: 15921845
• Report Number: 3011623994-2022-00124
• Device Sequence Number: 6699150
• Product Code: HWE
• UDI-Device Identifier: 00853114006372
• UDI-Public: 00853114006372
• Combination Product (Y/N): N
• Initial Reporter State: FL
• Initial Reporter Country: US
• PMA/510(K) Number: N/A-CLASS I
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2022
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 12/05/2022

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 Expiration Date: 06/21/2025
• Device Model Number: 1405-2579
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 11/04/2022
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 10/26/2022
• Initial Report FDA Received Date: 12/05/2022
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 06/21/2022
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Patient Sex: Female