MAUDE Adverse Event Report: K2M, INC. FIXED SCREW, SELF-TAPPING; SIZE Ø4.0X16 MM; APPLIANCE, FIXATION, SPINAL INTERVERTEBRAL BODY

Catalog Number	8801-14016CA
Medical Device Problem Code	Fracture (1260)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	10/01/2022
Type of Reportable Event	Serious Injury
Event or Problem Description
It was reported that a patient was revised to address four fractured ozark fixed self-tapping screws.Fragments of the fractured screws remain in the patient's vertebral bodies as the surgeon was unable to remove them.This report captures the first of four screws.
Additional Manufacturer Narrative
Additional data: d4, h4 h6 codes have been updated to reflect receipt of the device and conclusion of the investigation.
Event or Problem Description
It was reported that a patient was revised to address four fractured ozark fixed self-tapping screws.Fragments of the fractured screws remain in the patient's vertebral bodies as the surgeon was unable to remove them.This report captures the first of four screws.

• Brand Name: FIXED SCREW, SELF-TAPPING; SIZE Ø4.0X16 MM
• Common Device Name: APPLIANCE, FIXATION, SPINAL INTERVERTEBRAL BODY
• 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: 17375801
• Report Number: 3004774118-2023-00092
• Device Sequence Number: 6638883
• Product Code: KWQ
• UDI-Device Identifier: 10888857391857
• UDI-Public: 10888857391857
• Combination Product (Y/N): N
• Initial Reporter Country: IT
• PMA/510(K) Number: K172104
• 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: Pharmacist
• Type of Report: Initial,Followup
• Report Date (Section B): 12/21/2023

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 Catalogue Number: 8801-14016CA
• Device Lot Number: JKWB
• 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: 07/13/2023
• Supplement Date Received by Manufacturer: 11/30/2023
• Initial Report FDA Received Date: 07/24/2023
• Supplement Report FDA Received Date: 12/21/2023
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 06/14/2019
• 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: 36 YR
• Patient Sex: Female
• Patient Weight: 62 KG