MAUDE Adverse Event Report: MDT SOFAMOR DANEK PUERTO RICO MFG CD HORIZON® SPINAL SYSTEM; APPLIANCE, FIXATION, SPINAL INTERLAMINAL

Catalog Number	7575540
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Codes	Pain (1994); No Code Available (3191)
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Revision surgery.Neither the device nor applicable imaging films were returned to manufacturer for evaluation therefore we are unable to determine the definitive cause of event.
Event or Problem Description
It was reported that patient underwent a sextant surgery in which screws were implanted at l5-s1.Post-op, the screws broke due to which the patient had back pain.On (b)(6) 2017, a revision surgery was performed in which the broken screws were removed and replaced with 2 new screws.
Additional Manufacturer Narrative
Product analysis :visual inspection confirms the bone screw disassembled from the mas head.The ring and crown are still assembled in the head.Microscopic examination of the mas assembly identified a portion of the retaining ring is fully seated, but has been sheared through the cross sectional area on both sides of the retaining ring gap, which would reduce the force required for bone screw detachment.The remaining sheared through portion of the ring appears to be deformed and bent away from the head.The remaining portion of the retaining ring is still seated in the groove of the head.Dimensional inspection of the bone screw head diameter found to be within print specification.After completed analysis, no evidence was found that would suggest a defect in design or manufacturing of the implant.The above observations are consistent with overload as the mechanism of failure.
Additional Manufacturer Narrative
If information is provided in the future, a supplemental report will be issued.

• Brand Name: CD HORIZON® SPINAL SYSTEM
• Common Device Name: APPLIANCE, FIXATION, SPINAL INTERLAMINAL
• Manufacturer (Section D): MDT SOFAMOR DANEK PUERTO RICO MFG; barrio marianna rd 909, km0.4; humacao PR 00792
• MDR Report Key: 6375352
• Report Number: 1030489-2017-00448
• Device Sequence Number: 1251873
• Product Code: KWP
• UDI-Device Identifier: 00885074030630
• UDI-Public: 00885074030630
• Combination Product (Y/N): N
• Initial Reporter Country: GM
• PMA/510(K) Number: K032265
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2016
• Device Explanted Year: 2017
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 04/26/2017

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?: Yes
• Operator of Device: Health Professional
• Device Catalogue Number: 7575540
• Device Lot Number: H5266309
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 04/24/2017
• Initial Date Received by Manufacturer: 02/06/2017
• Supplement Date Received by Manufacturer: Not provided; 04/26/2017
• Initial Report FDA Received Date: 03/03/2017
• Supplement Report FDA Received Date: 04/28/2017; 09/29/2017
• 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: 40 YR
• Patient Weight: 84