MAUDE Adverse Event Report: WRIGHTS LANE SYNTHES USA PRODUCTS LLC ONE-THIRD TUBULAR PLATE WITH COLLAR 7 HOLES/85MM; PLATE, FIXATION, BONE

Model Number	241.37
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Unspecified Infection (1930); No Code Available (3191)
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Complainant part is not expected to be returned for manufacturer review/investigation.The investigation could not be completed; no conclusion could be drawn, as no product was received.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.(b)(4).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 on an unknown date there was a hardware removal of the one third tubular plate with 7 holes and unknown screws due to infection.The tubular plate and unknown screws were implanted on an unknown date.After the procedure, there was a presence of infection.Procedure was successfully completed and all hardware were removed.This complaint involves eight (8) devices.This is 1 of 8 for report (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 history lot part number: 241.37, lot number: 7820676, part manufacture date: 10 oct 2014, manufacturing location: elmira, part expiration date: n/a, nonconformance noted: n/a.Dhr record review: a review of the device history record revealed no complaint related anomalies.The device history record shows this lot of one-third tubluar plate with collar 7 holes/85mm was processed through the normal manufacturing and inspection operations with no non-conformances or rework noted.The lot quantity of (b)(4) pieces met all dimensional, visual and packaging criteria at the time of release with no issues documented during the manufacture that would contribute to this complaint condition.Device history batch part number: 316l**pi9.00x1.00, lot number: 7617332, part manufacture date: 25 feb 2014, manufacturing location: elmira, part expiration date: n/a.Dhr record review: a review of the device history record revealed no complaint related anomalies.The device history record shows this lot of one-third tubluar plate with collar 7 holes/85mm was processed through the normal manufacturing and inspection op.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: ONE-THIRD TUBULAR PLATE WITH COLLAR 7 HOLES/85MM
• 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: 9705697
• Report Number: 2939274-2020-00799
• Device Sequence Number: 19751743
• Product Code: HRS
• UDI-Device Identifier: 10886982166883
• UDI-Public: (01)10886982166883
• Combination Product (Y/N): N
• Initial Reporter State: VT
• Initial Reporter Country: US
• PMA/510(K) Number: EXEMPT
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Explanted Year: 2020
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 01/22/2020

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: 241.37
• Device Catalogue Number: 241.37
• Device Lot Number: 7820676
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 01/22/2020
• Supplement Date Received by Manufacturer: 02/17/2020
• Initial Report FDA Received Date: 02/13/2020
• Supplement Report FDA Received Date: 03/12/2020
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 41 YR