MAUDE Adverse Event Report: INTEGRITY IMPLANTS INC FLAREHAWK INTERBODY FUSION SYSTEM; LUMBAR INTERVERTEBRAL BODY FUSION DEVICE

Model Number	ASY-00034
Health Effect - Clinical Code	Foreign Body In Patient (2687)
Date of Event	03/02/2020
Type of Reportable Event	Serious Injury
Event or Problem Description
The company was made aware that the patient was scheduled for a revision surgery due to pseudarthrosis.It was reported that during the index surgery, full implant deployment did not occur; and the surgeon removed the shim component, but left the shell component in the disc space.During the revision surgery the shell component was removed successfully.The explanted shell was not returned to the company for evaluation.

• Brand Name: FLAREHAWK INTERBODY FUSION SYSTEM
• Common Device Name: LUMBAR INTERVERTEBRAL BODY FUSION DEVICE
• Manufacturer (Section D): INTEGRITY IMPLANTS INC; 354 hiatt drive; palm beach gardens, fl
• MDR Report Key: 9914565
• Report Number: 3012797630-2020-00002
• Device Sequence Number: 11470100
• Product Code: MAX
• UDI-Device Identifier: 00810004723474
• UDI-Public: (01)00810004723474(10)04190111
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K182114
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2019
• Device Explanted Year: 2020
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 04/01/2020

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: ASY-00034
• Device Catalogue Number: FHPACS0023SB
• Device Lot Number: 04190111
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 03/02/2020
• Initial Report FDA Received Date: 04/01/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 63 YR