MAUDE Adverse Event Report: MEDTRONIC SOFAMOR DANEK PUERTO RICO MFG DIVERGENCE STAND ALONE INTERBODY CAGE

Catalog Number	G6626745
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	10/12/2017
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Product code: intervertebral fusion device with integrated fixation, cervical.Neither the device nor films of applicable imaging studies were returned to the manufacturer for evaluation.Therefore, we are unable to determine the definitive cause of the reported event.If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
It was reported that patient was pre-operatively diagnosed with spinal stenosis and underwent anterior cervical discectomy and fusion (acdf) on c5-c7.During surgery, the locking mechanism of the implant broke and got separated from the implant when the surgeon attempted to turn it.No fragments were left in the patient.No patient complications were reported as a result of the event.

• Brand Name: DIVERGENCE STAND ALONE INTERBODY CAGE
• Manufacturer (Section D): MEDTRONIC SOFAMOR DANEK PUERTO RICO MFG; barrio marianna rd 909, km0.4; humacao PR 00792
• MDR Report Key: 7017636
• Report Number: 1030489-2017-02292
• Device Sequence Number: 13704437
• Product Code: OVE
• UDI-Device Identifier: 00643169337534
• UDI-Public: 00643169337534
• Combination Product (Y/N): N
• Initial Reporter State: NC
• Initial Reporter Country: US
• PMA/510(K) Number: K141599
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2017
• Device Explanted Year: 2017
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 11/10/2017

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
• Operator of Device: Health Professional
• Device Expiration Date: 02/14/2025
• Device Catalogue Number: G6626745
• Device Lot Number: H5326360
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 10/12/2017
• Initial Report FDA Received Date: 11/10/2017
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1