MAUDE Adverse Event Report: WRIGHTS LANE SYNTHES USA PRODUCTS LLC TFNA FENESTRATED HELICAL BLADE 95MM - STERILE; ROD, FIXATION, INTRAMEDULLARY

Model Number	04.038.395S
Medical Device Problem Code	Migration (4003)
Health Effect - Clinical Code	No Code Available (3191)
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Additional device product code: ktt.Complainant part is not expected to be returned for manufacturer review/investigation.(b)(4).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 an unknown date, the trochanteric fixation nail advanced (tfna) blade system experienced a cutout for an intertrochanteric fracture.The system had used traumacem augmentation but still experienced a cutout.It is unknown if there was a surgical delay.Procedure and patient outcome are unknown.This report captures the second application of traumacem augmentation but still experienced a cutout, while related complaint (b)(4) captures the tfna helical blade system experienced a cut out.Concomitant devices reported: titanium cannulated tfna nail (part# 04.037.042s, lot#unknown, quantity 1); titanium locking screw stardriver (part# 04.005.524s, lot#unknown, quantity unknown); traumacem injectable bone cement (part#07.702.040s, lot#unknown, quantity 1); traumacem injectable bone cement (part# 03.702.150s, lot#unknown, quantity 1); traumacem injectable bone cement (part# 03.702.121s, lot#unknown, quantity 1).This report is for one (1) tfna fenestrated helical blade.This is report 1 of 1 for complaint (b)(4).
Additional Manufacturer Narrative
Depuy synthes is submitting this report pursuant to the provisions of 21 cfr, part 803.This report may be based on information which depuy synthes has not been able to investigate or verify prior to the required reporting date.This report does not reflect a conclusion by fda, depuy synthes or its employees that the report constitutes an admission that the device, depuy synthes, or its employees caused or contributed to the potential event described in this report.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.
Additional Manufacturer Narrative
Depuy synthes is submitting this report pursuant to the provisions of 21 cfr, part 803.This report may be based on information which depuy synthes has not been able to investigate or verify prior to the required reporting date.This report does not reflect a conclusion by fda, depuy synthes or its employees that the report constitutes an admission that the device, depuy synthes, or its employees caused or contributed to the potential event described in this report.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.

• Brand Name: TFNA FENESTRATED HELICAL BLADE 95MM - STERILE
• Common Device Name: ROD, FIXATION, INTRAMEDULLARY
• Manufacturer (Section D): WRIGHTS LANE SYNTHES USA PRODUCTS LLC; 1302 wrights lane east; west chester PA 19380
• MDR Report Key: 8578247
• Report Number: 2939274-2019-57819
• Device Sequence Number: 1537549
• Product Code: HSB
• UDI-Device Identifier: 10886982099273
• UDI-Public: (01)10886982099273
• Combination Product (Y/N): N
• PMA/510(K) Number: K160167
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Explanted Year: 2019
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 04/03/2019

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?: Yes
• Operator of Device: Health Professional
• Device Model Number: 04.038.395S
• Device Catalogue Number: 04.038.395S
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 04/04/2019
• Supplement Date Received by Manufacturer: 05/02/2019; 05/30/2019
• Initial Report FDA Received Date: 05/03/2019
• Supplement Report FDA Received Date: 05/30/2019; 05/31/2019
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: LOCKSCR 5 L34 F/NAILS TAN LIGHT GREEN; TI CANN TFNA 170MM; TRAUMA SYRING KIT 4*1 ML 2*2 ML; TRAUMACEM V+ CEMENT KIT 10 ML; TRAUMACEM(TM) V+ INJECTION CANNULA FOR TFNA; LOCKSCR 5 L34 F/NAILS TAN LIGHT GREEN; TI CANN TFNA 170MM; TRAUMA SYRING KIT 4*1 ML 2*2 ML; TRAUMACEM V+ CEMENT KIT 10 ML; TRAUMACEM(TM) V+ INJECTION CANNULA FOR TFNA
• Outcome Attributed to Adverse Event: Required Intervention