MAUDE Adverse Event Report: MEDOS INTERNATIONAL SÃ RL CH SINGLE-INNER SETSCREW; ORTHOSIS, SPINAL PEDICLE FIXATION, FOR DEGENERATIVE DISC DISEASE

Model Number 179788645

Device Problem Loose or Intermittent Connection (1371)

Patient Problem No Code Available (3191)

Event Type  Injury  

Manufacturer Narrative

(b)(4).The device is available for evaluation.Investigation will be conducted.Follow up will be filed with the investigation results.If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.

Event Description

Revision fusion: (b)(6) hospital, (b)(6) 2019.Primary implant date: (b)(6) 2018.Revision for dislodged rods.Set screws were no longer in screw heads right side rod no longer stable concomitant device reported: unknown rod (part# unknown, lot# unknown, quantity one).This complaint involves 11 (eleven) devices.

Manufacturer Narrative

Product complaint # (b)(4).Udi: (b)(4).Complaint description: revision fusion: (b)(6).Primary implant date: (b)(6) 2018.Revision for dislodged rods.Set screws were no longer in screw heads right side rod no longer stable concomitant device reported.Concomitant device reported: unknown rod (part# unknown, lot# unknown, quantity one) investigation flow device interaction/functional.Visual inspection: visual inspection of the returned device revealed no damage aside from minor cosmetic surface scuffing on the etched-surface and non-etched surfaces, which was consistent with implantation and explantation.This damage would not have contributed to the complaint condition or another function/performance/safety issue.No other issues to any other feature was observed.Cosmetic damage was noted to the returned concomitant devices, which is consistent with implantation and explantation; however, no issues were observed which would have contributed to the complaint condition or another function/performance/safety issue.Functional test: the set screw was able to assemble with the concomitant devices without issue.No loose condition was observed.Dimensional inspection.Drawing: 1797-02-001 rev.A.Feature: threads, major diameter.Specification: 8.725 - 8.775mm.Measurement: 8.763mm.Result: conforming.Drawing: 1797-02-001 rev.A.Feature: height.Specification: 3.850 - 3.950mm.Measurement: 3.897mm.Result: conforming.All measurements taken with om147.Document/specification review the following drawings were reviewed during investigation: 1797-02/12-000 rev.B 1797-02-001 rev.A no design issues were identified during investigation.Conclusion: the complaint was not confirmed with investigation.There were no issues during the manufacture of this product that would contribute to this complaint condition.During the investigation, no product design issues or discrepancies were observed that may have contributed to the complaint condition.Additional monitoring for any potential safety signals will be conducted through complaint trending and other post market safety surveillance activities.Therefore, it has been determined that no corrective and/or preventive action is proposed.The dhr of product code 179702000, lot 192990, was electronically reviewed and no non-conformances were observed during the manufacturing process.The product was released on (b)(6) 2018.Qty 454.

• Brand Name: SINGLE-INNER SETSCREW
• Type of Device: ORTHOSIS, SPINAL PEDICLE FIXATION, FOR DEGENERATIVE DISC DISEASE
• Manufacturer (Section D): MEDOS INTERNATIONAL SÃ RL CH; chemin-blanc 38; le locle 02400 ; SZ 02400
• MDR Report Key: 8902362
• MDR Text Key: 155243880
• Report Number: 1526439-2019-51987
• Device Sequence Number: 1
• Product Code: NKB
• UDI-Device Identifier: 10705034081403
• UDI-Public: (01)10705034081403
• Combination Product (y/n): N
• PMA/PMN Number: K160904
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative,foreig
• Type of Report: Initial,Followup
• Report Date: 07/29/2019

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 08/16/2019
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: 179788645
• Device Catalogue Number: 179702000
• Device Lot Number: 192990
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 09/24/2019
• Date Manufacturer Received: 09/24/2019
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1
• Patient Outcome(s): Required Intervention