MAUDE Adverse Event Report: SI-BONE, INC. IFUSE IMPLANT SYSTEM; ORTHOPEDIC ROD

Model Number	7055-90
Medical Device Problem Code	Malposition of Device (2616)
Health Effect - Clinical Codes	Undesired Nerve Stimulation (1980); Arthralgia (2355); Nerve Proximity Nos (Not Otherwise Specified) (2647)
Date of Event	08/12/2016
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Based on the information provided, review of the surgical technique manual, ifu, certificates of analysis and fmea, there is no indication of device failure and no indication that the device was out of specification.The most probable root cause is a malpositioned implant impinging on or breaching the neuroforamen.
Event or Problem Description
The patient had a right side si joint arthrodesis in (b)(6) 2016 where three implants were placed.The patient complained of radicular pain after the initial surgery.The patient presented to a different surgeon that determined that the middle implant was malpositioned and possibly impinging or breaching the neuroforamen.In (b)(6) 2016, the surgeon performed a revision surgery where he removed the middle implant.No other preexisting implants were adjusted or removed.The status of the patient following the revision procedure is not yet known.

• Brand Name: IFUSE IMPLANT SYSTEM
• Common Device Name: ORTHOPEDIC ROD
• Manufacturer (Section D): SI-BONE, INC.; 3055 olin avenue; suite 2200; san jose CA 95128 2066
• MDR Report Key: 5879258
• Report Number: 3007700286-2016-00059
• Device Sequence Number: 16485398
• Product Code: OUR
• UDI-Device Identifier: 00859256003316
• UDI-Public: 00859256003316
• Combination Product (Y/N): N
• Initial Reporter State: CA
• Initial Reporter Country: US
• PMA/510(K) Number: K080398
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2016
• Device Explanted Year: 2016
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 08/16/2016

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 Expiration Date: 06/30/2020
• Device Model Number: 7055-90
• Device Lot Number: 373338
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 08/12/2016
• Initial Report FDA Received Date: 08/16/2016
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 84 YR