MAUDE Adverse Event Report: K2M, INC. XT SUPPORT TOWER; ORTHOPEDIC MANUAL SURGICAL INSTRUMENT

Model Number	5101-90218
Medical Device Problem Code	Mechanical Jam (2983)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	03/08/2023
Type of Reportable Event	Malfunction
Event or Problem Description
A company representative reported that during a scoliosis correction case an everest xt support tower and an everest xt support tower reducer jammed / became stuck together.The procedure was completed successfully with a 10 minute surgical delay and no adverse consequence to the patient.This report is for the everest xt support tower.
Additional Manufacturer Narrative
H6 coding has been updated to reflect completion of the investigation.No product returned.
Event or Problem Description
A company representative reported that during a scoliosis correction case an everest xt support tower and an everest xt support tower reducer jammed / became stuck together.The procedure was completed successfully with a 10 minute surgical delay and no adverse consequence to the patient.This report is for the everest xt support tower.

• Brand Name: XT SUPPORT TOWER
• Common Device Name: ORTHOPEDIC MANUAL SURGICAL INSTRUMENT
• 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: 16587171
• Report Number: 3004774118-2023-00035
• Device Sequence Number: 4681625
• Product Code: LXH
• UDI-Device Identifier: 10888857325968
• UDI-Public: 10888857325968
• Combination Product (Y/N): N
• Initial Reporter Country: UK
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 07/20/2023

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 Model Number: 5101-90218
• Device Catalogue Number: 5101-90218
• Device Lot Number: GBBL
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 03/08/2023
• Supplement Date Received by Manufacturer: 06/27/2023
• Initial Report FDA Received Date: 03/21/2023
• Supplement Report FDA Received Date: 07/20/2023
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 09/28/2017
• Is the Device Labeled for Single Use? (Y/N): No
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Reuse
• Patient Sequence Number: 1
• Patient Sex: Unknown