MAUDE Adverse Event Report: GLOBUS MEDICAL, INC. ANTHEM PROXIMAL TIBIA PLATING SYSTEM; ANTHEM LATERAL PROXIMAL TIBIA PLATE XR, LEFT, 6 HOLE, 140MM, SS

Model Number	2187.3106
Medical Device Problem Code	Use of Device Problem (1670)
Health Effect - Clinical Code	Insufficient Information (4580)
Date of Event	08/11/2023
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that a revision surgery was needed to replace 3.5mm grafting screws that backed out of an anthem lateral proximal tibia plate xr, left, 6 hole, 140mm, ss post operatively.
Additional Manufacturer Narrative
This report is being resubmitted for an incident that occurred earlier.Neither the device or any imaging could be provided for evaluation.No determinations could be made as to the cause of the reported issue.

• Brand Name: ANTHEM PROXIMAL TIBIA PLATING SYSTEM
• Common Device Name: ANTHEM LATERAL PROXIMAL TIBIA PLATE XR, LEFT, 6 HOLE, 140MM, SS
• Manufacturer (Section D): GLOBUS MEDICAL, INC.; 2560 general armistead avenue; audubon PA 19403
• Manufacturer (Section G): GLOBUS MEDICAL, INC.; 2560 general armistead avenue; audubon PA 19403
• Manufacturer Contact: daniel paul ; 2560 general armistead avenue; audubon, PA 19403 ; 6109301800
• MDR Report Key: 18838076
• Report Number: 3004142400-2023-00140
• Device Sequence Number: 7486404
• Product Code: HRS
• UDI-Device Identifier: 00889095613490
• UDI-Public: 00889095613490
• Combination Product (Y/N): N
• Initial Reporter State: PA
• Initial Reporter Country: US
• PMA/510(K) Number: K173166
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2023
• Device Explanted Year: 2023
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 03/01/2024

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: 2187.3106
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 08/11/2023
• Initial Report FDA Received Date: 03/05/2024
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• 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: Other
• Patient Sex: Unknown