MAUDE Adverse Event Report: LDR MÉDICAL ROI-C IMPLANT 14X15.5 H5; ROI-C TITANIUM-COATED IMPLANT SYSTEM

Catalog Number	MC1321P
Medical Device Problem Code	Fracture (1260)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	12/06/2022
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Without a product return, no product evaluation is able to be conducted.Current information is insufficient to permit a valid conclusion about the cause of this event.If additional information is obtained that adds value to the relevant content of this report and/or a conclusion can be drawn, a follow-up report will be sent.
Event or Problem Description
It was reported that both roi-c plates were impacted into the same side of the cage (bottom side of holder/superior side of cage), causing the cage to break.The cage and both plates were removed and replaced to complete the procedure without patient impacts.
Additional Manufacturer Narrative
Corrections in d4: expiration date and udi number.Additional information in h4 and h6: component, investigation type, findings, and conclusions.Device evaluation: the product was not returned and no photos were provided, so an evaluation is unable to be performed.Root cause: a definitive root cause cannot be determined with the information provided.This event could possibly be attributed to the surgeon not tracking which pathway had an anchor inserted in it.Dhr review: per dhr review, the part was likely conforming when it left zimvie control.Device usage: this device is used for treatment.If additional information is obtained that adds value to the relevant content of this report, a follow-up report will be sent.
Event or Problem Description
It was reported that both roi-c plates were impacted into the same side of the cage (bottom side of holder/superior side of cage), causing the cage to break.The cage and both plates were removed and replaced to complete the procedure without patient impacts.

• Brand Name: ROI-C IMPLANT 14X15.5 H5
• Common Device Name: ROI-C TITANIUM-COATED IMPLANT SYSTEM
• Manufacturer (Section D): LDR MÉDICAL; quartier europe de l¿ouest; 5, rue de berlin; sainte-savine, na 10300 ; FR 10300
• Manufacturer (Section G): LDR MÉDICAL; quartier europe de l¿ouest; 5, rue de berlin; sainte-savine, na 10300 ; FR 10300
• Manufacturer Contact: kim martinez ; 10225 westmoor dr.; na; westminster, CO 80021 ; 3035144809
• MDR Report Key: 16023729
• Report Number: 3004788213-2022-00129
• Device Sequence Number: 12486311
• Product Code: ODP
• UDI-Device Identifier: 03662663016131
• UDI-Public: (01)03662663016131(17)270401(10)C92252
• Combination Product (Y/N): N
• Initial Reporter Country: FR
• PMA/510(K) Number: K091088
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2022
• Device Explanted Year: 2022
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Foreign,Health Professional,Company Representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 06/14/2023

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 Catalogue Number: MC1321P
• Device Lot Number: C92252
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 12/06/2022
• Supplement Date Received by Manufacturer: 06/12/2023
• Initial Report FDA Received Date: 12/21/2022
• Supplement Report FDA Received Date: 06/14/2023
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 05/30/2022
• 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: Unknown