MAUDE Adverse Event Report: K2M, INC., EVEREST SPINAL SYSTEM; PEDICAL SCREW SPINAL SYSTEM

Catalog Number E5112-06550

Device Problem Break (1069)

Patient Problems Device Embedded In Tissue or Plaque (3165); No Information (3190)

Event Date 08/03/2017

Event Type  malfunction  

Manufacturer Narrative

The subject product has not been returned for evaluation.Investigation still in progress.When investigation is complete, k2m, inc.Will file a supplemental report indicating the findings.

Event Description

On (b)(6) 2017 it was reported to k2m, inc.That during surgery the polyaxial screw broke.The fractured component was removed and surgery completed.

Manufacturer Narrative

A comprehensive investigation was immediately initiated on receipt of the complaint.The product was not returned to manufacturer for evaluation, and a thorough investigation could not be completed as the lot number has not been identified/confirmed in this case.Since the fractured components were not returned, no physical, chemical evaluation could be performed, and the root cause of the reported issue could not be ascertained.Over torque, impact or force could contribute to premature tab breakage.No single cause could be determined for this event.

Event Description

On (b)(6) 2017 it was reported to k2m, inc.That during surgery the screws extended tab broke prematurely resulting in significant delay of surgery.The fractured component was removed and surgery completed.

• Brand Name: EVEREST SPINAL SYSTEM
• Type of Device: PEDICAL SCREW SPINAL 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: sandra gilbert ; 600 hope parkway se; leesburg, VA 20175 ; 5719195195
• MDR Report Key: 6844839
• MDR Text Key: 85918513
• Report Number: 3004774118-2017-00116
• Device Sequence Number: 1
• Product Code: NKB
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K151727
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative,distri
• Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date: 08/07/2017

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
• Device Operator: Physician
• Device Catalogue Number: E5112-06550
• Device Lot Number: UNKNOWN
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Was the Report Sent to FDA?: No
• Initial Date Manufacturer Received: 08/07/2017
• Initial Date FDA Received: 09/06/2017
• Supplement Dates Manufacturer Received: 08/07/2017
• Supplement Dates FDA Received: 10/04/2017
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1