MAUDE Adverse Event Report: SYNTHES GMBH 2.7MM/3.5MM TI VA-LCP LAT DSTL HUM PL 1H/LT/69MM SHRT-STER; PLATE, FIXATION, BONE

Catalog Number	04.117.901S
Medical Device Problem Code	Device-Device Incompatibility (2919)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	07/12/2023
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Depuy synthes is submitting this report pursuant to the provisions of 21 cfr, part 803.This report may be based on information which depuy synthes has not been able to investigate or verify prior to the required reporting date.This report does not reflect a conclusion by fda, depuy synthes or its employees that the report constitutes an admission that the device, depuy synthes, or its employees caused or contributed to the potential event described in this report.If the information is unknown, not available or does not apply, the section/field of the form is left blank.H10 additional narrative: d2: additional procode: hwc d9: complainant part is not expected to be returned for manufacturer review/investigation.E3: initial reporter is a synthes employee.H3, h6: the investigation could not be completed; no conclusion could be drawn, as no product was received.Based on the information available, it has been determined that no corrective and/or preventative action is proposed.This complaint will be accounted for and monitored via post market surveillance activities.If additional information is made available, the investigation will be updated as applicable.Manufacturing location: elmira / packaged, sterilized and released by: monument release to warehouse date: 06-jun-2022 expiration date: 01-jun-2032 part number: 04.117.901s 2.7mm/3.5mm ti va-lcp lat dstl hum pl 1h/lt/69mm shrt-sterile lot number: 828p396 (sterile) lot quantity: 48 this lot met all visual, sterility and packaging criteria at the time of release with no issues documented during the manufacture that would contribute to this complaint condition.Product was not returned.Based on the information available, it has been determined that no corrective and preventative action is proposed.This complaint will be accounted for and monitored via post market surveillance activities.If additional information is made available, the investigation will be updated as applicable.Device was used for treatment, not diagnosis.If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.
Event or Problem Description
Device report from japan reports an event as follows: it was reported that on (b)(6)2023, the patient underwent an orif surgery for distal humerus fracture.The affected area was fixed in the order of the medial plate, then the lateral plate.Initially, the screw was inserted at a fixed angle, but when it was checked with an image intensifier, it was found that the tip of the screw penetrated forward.The screw was removed and reinserted several times, but the angle did not change so the surgeon redrilled with a variable angle and inserted the screw.Near the end of the lateral plate fixation, the surgeon said that the 2nd screw from the distal side could not be locked and was coming out.The screw came out, so no screw was inserted in that screw hole.Only one screw could be inserted distally, so an additional screw was inserted from the distal lateral direction to the proximal lateral.The procedure was completed successfully with no surgical delay.No further information is available.This report is for a 2.7mm/3.5mm ti va-lcp lat dstl hum pl 1h/lt/69mm shrt-ster.This is report 1 of 3 for (b)(4).

• Brand Name: 2.7MM/3.5MM TI VA-LCP LAT DSTL HUM PL 1H/LT/69MM SHRT-STER
• Common Device Name: PLATE, FIXATION, BONE
• Manufacturer (Section D): SYNTHES GMBH; eimattstrasse 3; oberdorf 4436 ; SZ 4436
• Manufacturer (Section G): MONUMENT; 1101 synthes avenue; monument CO 80132
• Manufacturer Contact: kate karberg ; 1302 wright lane east; west chester, PA 19380 ; 3035526892
• MDR Report Key: 17415920
• Report Number: 8030965-2023-09507
• Device Sequence Number: 7038010
• Product Code: HRS
• UDI-Device Identifier: 10886982107077
• UDI-Public: (01)10886982107077
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: K120070
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Foreign,Health Professional,Company Representative
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial

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: 04.117.901S
• Device Lot Number: 828P396
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 07/12/2023
• Initial Report FDA Received Date: 07/28/2023
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 06/06/2022
• Is the Device Labeled for Single Use? (Y/N): Yes
• Usage of Device: Unknown
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: UNK - SCREWS: TRAUMA; VA LOCKSCR ø2.7 HEAD 2.4 SELF-TAP L30 TA
• Patient Sex: Unknown