MAUDE Adverse Event Report: PRECISION SPINE, INC REFORM TI MODULAR; MODULAR TULIP

Catalog Number	39-MT-0401
Medical Device Problem Code	Detachment of Device or Device Component (2907)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	06/04/2024
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
D4 lot number - unknown.H4 device manufacture date - unknown without lot identification.H3 device evaluation - the complaint device was ultimately implanted and cannot be returned for evaluation.Without the opportunity to examine the complaint product no conclusions can be drawn regarding the root cause of the reported malfunction.Review of device history records and lot specific complaint history review were not possible without lot identification.Two-year complaint history review did not reveal a trend for reports of this nature for this part number.This report is number 1 of 2 mdrs filed for the same event (reference 3005739886-2024-00035).
Event or Problem Description
It was reported that a procedure was performed in australia on (b)(6) 2024, utilizing the reform mc midline cortical screw system.During the procedure the reform ti modular polyaxial tulip assembly (39-mt-0401) was assembled onto the midline cortical bone screw (59-bp-xxxx) on the nurses table.The assembled screw was loaded onto a t25 cannulated poly driver w/lock (c3164) and the driver was tightened and locked.The screw was placed into the patient and when the screwdriver was released from the screw the tulip disassembled from the screw and dropped into the wound.The tulip was retrieved using forceps and was snapped back onto the screw by the surgeon and the procedure was completed successfully.There was no patient injury and an approximate 5 minute delay to the procedure.

• Brand Name: REFORM TI MODULAR
• Common Device Name: MODULAR TULIP
• Manufacturer (Section D): PRECISION SPINE, INC; 2050 executive drive; pearl MS 39208
• Manufacturer (Section G): PRECISION SPINE, INC; 2050 executive drive; pearl MS 39208
• Manufacturer Contact: mike dawson ; 2050 executive drive; pearl, MS 39208 ; 6014204244
• MDR Report Key: 19689225
• Report Number: 3005739886-2024-00034
• Device Sequence Number: 15470563
• Product Code: KWP
• UDI-Device Identifier: 00840019932622
• UDI-Public: 00840019932622
• Combination Product (Y/N): N
• Initial Reporter Country: AS
• PMA/510(K) Number: K150856
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2024
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Foreign,Distributor
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 06/04/2024

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?: No
• Operator of Device: Health Professional
• Device Catalogue Number: 39-MT-0401
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 06/04/2024
• Initial Report FDA Received Date: 07/08/2024
• Was Device Evaluated by Manufacturer? (Y/N): No
• 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 Sex: Unknown