MAUDE Adverse Event Report: DEPUY SYNTHES SPINE EXPEDIUM VIPER; ORTHOSIS, SPINAL PEDICLE FIXATION, FOR DEGENERATIVE DISC DISEASE

Model Number	196789600
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Codes	Fall (1848); Failure of Implant (1924); Injury (2348)
Date of Event	09/06/2017
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
A complaint investigation will be performed.The complaint product is not available for the investigation.A supplemental report is not anticipated unless the results of the complaint investigation identify a corrective action or additional relevant information.Should the product become available, a physical evaluation will be conducted and a supplemental report filed with the results.If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.Not returned for evaluation.
Event or Problem Description
Revision scoliosis correction on (b)(6) 2017.Patient underwent primary correction (b)(6) 2010.3 years ago the patient had a fall and the screws broke just under the tulip and the cocr rods also broke.X-ray provided.Case is linked to 5109967 - this case captures the instrument issues that occurred during the revision procedure.

• Brand Name: EXPEDIUM VIPER
• Common Device Name: ORTHOSIS, SPINAL PEDICLE FIXATION, FOR DEGENERATIVE DISC DISEASE
• Manufacturer (Section D): DEPUY SYNTHES SPINE; 325 paramount drive; raynham MA 02767
• MDR Report Key: 6906915
• Report Number: 1526439-2017-10783
• Device Sequence Number: 11048139
• Product Code: NKB
• UDI-Device Identifier: 10705034295282
• UDI-Public: (01)10705034295282
• Combination Product (Y/N): N
• Initial Reporter Country: AS
• PMA/510(K) Number: K090648
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2010
• Device Explanted Year: 2017
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 09/06/2017

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: Physician
• Device Model Number: 196789600
• Device Catalogue Number: 196789600
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 09/06/2017
• Initial Report FDA Received Date: 10/02/2017
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention