MAUDE Adverse Event Report: WRIGHTS LANE SYNTHES USA PRODUCTS LLC 2.7MM/3.5MM VA-LCP MEDL DSTL HUMERUS PL 6H/RT/134MM-XLONG; PLATE, FIXATION, BONE

Model Number	02.117.406
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Nonunion/Delayed-union Bone Fracture (2369)
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Patient height reported as 167 centimeters.Additional product code: hwc.Complainant part is not expected to be returned for manufacturer review/investigation.Without a lot number the device history records review could not be completed.Product was not returned.Based on the information available, it has been determined that no corrective and/or preventative action is proposed.This complaint will be accounted for and monitored via post market surveillance activities.If additional information is made available, the investigation will be updated as applicable.Device was used for treatment, not diagnosis.If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.
Event or Problem Description
It was reported that on (b)(6) 2019, the patient underwent an unknown hardware removal procedure due to nonunion.The patient had a distal humerus fracture on unknown date.Four (4) 3.5 cortex screws, four (4) 3.5 locking screws, and two (2) 2.7 va locking screws were removed from the locking compression plate (lcp) extra-articular distal humerus plate and variable angle-locking compression plate (va-lcp) medial distal humerus plate.The surgeon decided to convert it into total elbow prosthesis.It is unknown if there was surgical delay.Procedure outcome and patient status are unknown.This report is for an va-lcp medial distal humerus plate.This is report 2 of 5 for (b)(4).

• Brand Name: 2.7MM/3.5MM VA-LCP MEDL DSTL HUMERUS PL 6H/RT/134MM-XLONG
• Common Device Name: PLATE, FIXATION, BONE
• Manufacturer (Section D): WRIGHTS LANE SYNTHES USA PRODUCTS LLC; 1302 wrights lane east; west chester PA 19380
• MDR Report Key: 8473438
• Report Number: 2939274-2019-57215
• Device Sequence Number: 1501569
• Product Code: HRS
• UDI-Device Identifier: 10886982036605
• UDI-Public: (01)10886982036605
• Combination Product (Y/N): N
• Initial Reporter State: TX
• Initial Reporter Country: US
• PMA/510(K) Number: K120070
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 03/08/2019

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?: No
• Operator of Device: Health Professional
• Device Model Number: 02.117.406
• Device Catalogue Number: 02.117.406
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 03/08/2019
• Initial Report FDA Received Date: 04/02/2019
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 64 YR
• Patient Weight: 124