MAUDE Adverse Event Report: KARL LEIBINGER MEDIZINTECHNIK GMBH & CO. KG INTERNAL DISTRACTOR CARDANIC FOR ACTIVATION ARM

Model Number	51-401-91-09
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	09/12/2016
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
This is one of three related mdrs.Please refer to mdr 9610905-2016-00034 and 9610905-2016-00036.
Event or Problem Description
After the completion of the distraction phase the surgeon attempted to remove the activation arm.During the attempted removal, the posterior left foot plate became loose form the distraction body.The left distractor was removed on (b)(6) 2016.
Additional Manufacturer Narrative
Methods: visual inspection, stereo microscopic inspection, and performance test on a standard sample plate results: the devices were optically assessed and stereo microscopically investigated in the lab.The stereo microscopic investigation revealed surface damage but no breakage.Further observation determined there were no indications of material or manufacturing defects discovered.The developer tested the function and there was no abnormality found.The product history device records were also reviewed based on the lot number provided and revealed no abnormalities.Assessment conclusion : the results of the investigation could not determine the root cause for malfunction.If further information can be gathered that might add value to the contents of the investigated report, an additional follow-up report will be submitted.This is one of three related mdrs.Please refer to mdr 9610905-2016-00034 and 9610905-2016-00036.

• Brand Name: INTERNAL DISTRACTOR CARDANIC FOR ACTIVATION ARM
• Common Device Name: DISTRACTOR
• Manufacturer (Section D): KARL LEIBINGER MEDIZINTECHNIK GMBH & CO. KG; kolbinger strabe 10; muhlheim/donau, 78570 ; GM 78570
• MDR Report Key: 5997666
• Report Number: 9610905-2016-00035
• Device Sequence Number: 98257
• Product Code: MQN
• UDI-Device Identifier: 00888118080745
• UDI-Public: (01)00888118080745
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K010139
• 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,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 09/12/2016

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: No Information
• Device Model Number: 51-401-91-09
• Device Lot Number: 33150320
• Was Device Available for Evaluation?: Yes
• Type of Report(Section G): FDA Requested
• Initial Date Received by Manufacturer: Not provided
• Supplement Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 10/04/2016
• Supplement Report FDA Received Date: 11/07/2016
• 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: Other
• Patient Age: 5 MO