MAUDE Adverse Event Report: K2M, INC. POLYAXIAL SCREW; Ø5.0X28 MM; POSTERIOR CERVICAL SCREW SYSTEM

Catalog Number	7601-05028
Medical Device Problem Code	Fracture (1260)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	08/31/2024
Type of Reportable Event	Malfunction
Event or Problem Description
A company representative reported that the head of a yukon oct polyaxial screw fractured from the shank of the screw intra-operatively.The procedure was completed successfully with a thirty minute surgical delay and with the screw shaft remaining in the patient.
Additional Manufacturer Narrative
H6 codes have been updated to reflect conclusion of the investigation.
Event or Problem Description
A company representative reported that the head of a yukon oct polyaxial screw fractured from the shank of the screw intra-operatively.The procedure was completed successfully with a thirty minute surgical delay and with the screw shaft remaining in the patient.

• Brand Name: POLYAXIAL SCREW; Ø5.0X28 MM
• Common Device Name: POSTERIOR CERVICAL SCREW SYSTEM
• 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: matthew kelleher ; 2 pearl court; allendale, NJ 07401 ; 2017608000
• MDR Report Key: 20345571
• Report Number: 3004774118-2024-00090
• Device Sequence Number: 18158112
• Product Code: NKG
• UDI-Device Identifier: 10888857350014
• UDI-Public: 10888857350014
• Combination Product (Y/N): N
• Initial Reporter State: TX
• Initial Reporter Country: US
• PMA/510(K) Number: K171444
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 01/14/2025

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: 7601-05028
• Device Lot Number: UNKNOWN
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 09/01/2024
• Supplement Date Received by Manufacturer: 12/20/2024
• Initial Report FDA Received Date: 10/01/2024
• Supplement Report FDA Received Date: 01/14/2025
• 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
• Patient Sex: Unknown