MAUDE Adverse Event Report: ACUTE INNOVATIONS, LLC RIBLOC 10MM X 46MM RIB PLATE; PLATE, FIXATION, BONE

Model Number	RBP1102
Health Effect - Clinical Codes	Pain (1994); Discomfort (2330)
Date of Event	04/29/2016
Type of Reportable Event	Serious Injury
Event or Problem Description
Patient was originally plated (b)(6) 2013.Revision surgery was performed to remove plate due to patient pain and discomfort.No device deficiency is alleged.Plate was not returned for anaylsis.

• Brand Name: RIBLOC 10MM X 46MM RIB PLATE
• Common Device Name: PLATE, FIXATION, BONE
• Manufacturer (Section D): ACUTE INNOVATIONS, LLC; 21421 nw jacobson road; suite 700; hillsboro OR 97124
• MDR Report Key: 5880988
• Report Number: 3005670412-2016-00005
• Device Sequence Number: 19164102
• Product Code: HRS
• UDI-Device Identifier: 10814493010029
• UDI-Public: 10814493010029
• Combination Product (Y/N): N
• Initial Reporter State: MI
• Initial Reporter Country: US
• PMA/510(K) Number: K113318
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2013
• Device Explanted Year: 2016
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Other
• 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: Physician
• Device Model Number: RBP1102
• Device Catalogue Number: RBP1102
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 04/28/2016
• 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