MAUDE Adverse Event Report: K2M, INC. STRAIGHT ROD; SIZE Ø5.5X500 MM, TI; THORACOLUMBOSACRAL PEDICLE SCREW SYSTEM

Model Number	101-555500-G1
Medical Device Problem Code	Fracture (1260)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	01/09/2023
Type of Reportable Event	Serious Injury
Event or Problem Description
It was reported that approximately 18 months post-operatively a denali straight rod fractured.Revision surgery was performed and the rod was replaced.
Event or Problem Description
It was reported that approximately 18 months post-operatively a denali straight rod fractured.Revision surgery was performed and the rod was replaced.
Additional Manufacturer Narrative
H6: coding has been updated to reflect device evaluation and investigation conclusion.

• Brand Name: STRAIGHT ROD; SIZE Ø5.5X500 MM, TI
• Common Device Name: THORACOLUMBOSACRAL PEDICLE SCREW SYSTEM
• Manufacturer (Section D): K2M, INC.; 600 hope parkway se; leesburg VA 20175
• Manufacturer (Section G): K2M, INC.; 600 hope parkway se; leesburg VA 20175
• Manufacturer Contact: rita karan ; 2 pearl court; allendale, NJ 07401 ; 2017608000
• MDR Report Key: 16259726
• Report Number: 3004774118-2023-00007
• Device Sequence Number: 17817909
• Product Code: NKB
• UDI-Device Identifier: 10888857419872
• UDI-Public: 10888857419872
• Combination Product (Y/N): N
• Initial Reporter Country: GM
• PMA/510(K) Number: K141873
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2021
• Device Explanted Year: 2023
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Health Professional
• Initial Reporter Occupation: Nurse
• Type of Report: Initial,Followup
• Report Date (Section B): 05/17/2023

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: 101-555500-G1
• Device Catalogue Number: 101-555500-G1
• Device Lot Number: MMHY-427432
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 01/16/2023
• Supplement Date Received by Manufacturer: 04/20/2023
• Initial Report FDA Received Date: 01/27/2023
• Supplement Report FDA Received Date: 05/17/2023
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 10/13/2020
• 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
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 69 YR
• Patient Sex: Female
• Patient Weight: 72 KG