MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a company representative report with the FDA on 2017-12-19 for PROFORM HIP SYSTEM SC2677-40 manufactured by Stelkast Inc..
[95636474]
An evaluation of the device cannot be performed as the device was not returned.
Patient Sequence No: 1, Text Type: N, H10
[95636475]
During a left hip surgery, a 6. 5 x 40mm cancellous bone screw broke while being implanted. Only the head of the screw was retrieved. The distal third of the screw remains in the patient.
Patient Sequence No: 1, Text Type: D, B5
| Report Number | 2530191-2017-00173 |
| MDR Report Key | 7128542 |
| Report Source | COMPANY REPRESENTATIVE |
| Date Received | 2017-12-19 |
| Date of Report | 2017-12-19 |
| Date of Event | 2017-12-08 |
| Date Mfgr Received | 2017-12-08 |
| Device Manufacturer Date | 2015-02-02 |
| Date Added to Maude | 2017-12-19 |
| Event Key | 0 |
| Report Source Code | Manufacturer report |
| Manufacturer Link | Y |
| Number of Patients in Event | 0 |
| Adverse Event Flag | 3 |
| Product Problem Flag | 3 |
| Reprocessed and Reused Flag | 3 |
| Reporter Occupation | MEDICAL EQUIPMENT COMPANY TECHNICIAN/REPRESENTATIVE |
| Health Professional | 3 |
| Initial Report to FDA | 3 |
| Report to FDA | 3 |
| Event Location | 3 |
| Manufacturer Contact | MR. JOHN REYHER |
| Manufacturer Street | 200 HIDDEN VALLEY ROAD |
| Manufacturer City | MCMURRAY PA 15317 |
| Manufacturer Country | US |
| Manufacturer Postal | 15317 |
| Manufacturer Phone | 7249416368 |
| Manufacturer G1 | STELKAST INC. |
| Manufacturer Street | 200 HIDDEN VALLEY ROAD |
| Manufacturer City | MCMURRAY PA 15317 |
| Manufacturer Country | US |
| Manufacturer Postal Code | 15317 |
| Single Use | 3 |
| Previous Use Code | 3 |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | PROFORM HIP SYSTEM |
| Generic Name | 6.5MM CANCELLOUS BONE SCREW |
| Product Code | JDO |
| Date Received | 2017-12-19 |
| Model Number | SC2677-40 |
| Lot Number | 33173250202 |
| Operator | HEALTH PROFESSIONAL |
| Device Availability | N |
| Device Eval'ed by Mfgr | R |
| Device Sequence No | 1 |
| Device Event Key | 0 |
| Manufacturer | STELKAST INC. |
| Manufacturer Address | 200 HIDDEN VALLEY ROAD MCMURRAY PA 15317 US 15317 |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 1. Required No Informationntervention | 2017-12-19 |