MAUDE Adverse Event Report: WARSAW ORTHOPEDICS VERTEX RECONSTRUCTION SYSTEM; APPLIANCE, FIXATION, SPINAL INTERLAMINAL

Model Number	7753500
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	08/11/2017
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The device was not returned to the manufacturer for evaluation.Therefore, we are unable to determine the definitive cause of the reported event.As per image review the submitted images appear to display complaint product.Unable to identify photographic representation of complaint condition.A good faith effort will be made to obtain the applicable information relevant to the report.If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
Pre-op diagnosis: canal stenosis levels implanted: c3-t1 it was reported that intra-op, the set screw broke.The product came in contact with the patient.No fragments remained inside the patient.No patient complications reported as the result of the event.
Additional Manufacturer Narrative
Product analysis: visually confirmed the mas connector is broken at approximately the base of the connector hex head.The bottom portion of the implant was missing and not returned for analysis.Optical examination of the thread form did not identify thread damage on the returned portion of the implant.Optical examination of the fracture surface appears to emanate from the root of the internal thread tooth outward, is roughly parallel with the tooth angulation, with evidence of linear shear lines on the fracture surface.Witness marks and material deformation identified on the external hex, consistent with torsional overload.The location of the fracture at the base of the connector head, the fracture surface angulation relative to the thread axis, absence of thread damage and direction of shear lines are consistent with torsional overload.If information is provided in the future, a supplemental report will be issued.
Additional Manufacturer Narrative
Medtronic is submitting this report to comply with fda reporting regulations under 21 cfr parts 4 and 803.This report is based upon information obtained by medtronic, which the company may not have been able to fully investigate or verify prior to the date the report was required by the fda.Medtronic has made reasonable efforts to obtain more complete information and has provided as much relevant information as is available to the company as of the submission date of this report.This report does not constitute an admission or a conclusion by fda, medtronic, or its employees that the device, medtronic, or its employee caused or contributed to the event described in the report.In particular, this report does not constitute an admission by anyone that the product described in this report has any ¿defects¿ or has ¿malfunctioned¿.These words are included in the fda 3500a form and are fixed items for selection created by the fda to categorize the type of event solely for the purpose of regulatory reporting.Medtronic objects to the use of these words and others like them because of the lack of definition and the connotations implied by these terms.This statement should be included with any information or report disclosed to the public under the freedom of information act.Any required fields that are unpopulated are blank because the information is currently unknown or unavailable.A good faith effort will be made to obtain the applicable information relevant to the report.If information is provided in the future, a supplemental report will be issued.

• Brand Name: VERTEX RECONSTRUCTION SYSTEM
• Common Device Name: APPLIANCE, FIXATION, SPINAL INTERLAMINAL
• Manufacturer (Section D): WARSAW ORTHOPEDICS; 2500 silveus crossing; warsaw IN 46582
• Manufacturer (Section G): WARSAW ORTHOPEDICS; 2500 silveus crossing; warsaw IN 46582
• Manufacturer Contact: stacie ziemba ; 1800 pyramid place; memphis, TN 38132 ; 9013963133
• MDR Report Key: 6850972
• Report Number: 1030489-2017-02005
• Device Sequence Number: 1430334
• Product Code: KWP
• UDI-Device Identifier: 00613994448743
• UDI-Public: 00613994448743
• Combination Product (Y/N): N
• Initial Reporter Country: AS
• PMA/510(K) Number: K082728
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2017
• Device Explanted Year: 2017
• Reporter Type: Manufacturer
• Report Source: Foreign,Health Professional,Distributor
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 03/24/2022

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
• Operator of Device: Health Professional
• Device Model Number: 7753500
• Device Catalogue Number: 7753500
• Device Lot Number: 0180771W
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 01/27/2018
• Is the Reporter a Health Professional?: Yes
• Initial Date Received by Manufacturer: 08/11/2017
• Supplement Date Received by Manufacturer: 03/07/2018; 08/11/2017
• Initial Report FDA Received Date: 09/08/2017
• Supplement Report FDA Received Date: 04/06/2018; 03/24/2022
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 06/22/2011
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Patient Age: 86 YR
• Patient Sex: Female