INFUSE BONE GRAFT 7510050

MAUDE Adverse Event Report

MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a consumer report with the FDA on 2018-11-01 for INFUSE BONE GRAFT 7510050 manufactured by Medtronic Sofamor Danek Usa, Inc.

Event Text Entries

[125841512] (b)(4). Neither the device nor films of applicable imaging studies were returned to the manufacturer for evaluation. Therefore, we are unable to determine the definitive cause of the reported event. Although it is unknown if the device contributed to the reported event, we are filing this mdr for notification purposes. If information is provided in the future, a supplemental report will be issued.
Patient Sequence No: 1, Text Type: N, H10


[125841513] The patient was presented with following pre-op diagnosis: bilateral lumbar radiculopathy, degenerative spondylolisthesis, l4-l5, spinal stenosis, l3-l5, bilateral foraminal stenosis, l3-l5, degenerative disk disease, l3-s 1, status post laminectomy, l4-l5 with right diskectomy, status post postoperative infection, l4-l5, obesity. She underwent following procedures: redo bilateral laminectomies, l4-l5 with foraminotomies, partial laminectomy, l3-l4 with bilateral foraminotomies, neurolysis, right l4 nerve root, posterior lumbar interbody fusion, l4-l5, insertion of tricortical allograft prostheses, right l4-l5, posterolateral fusion, l4-l5, insertion of extra, extra small bone graft, insertion of allograft cancellous bone chips, insertion of autograft bone from the decompression, insertion of sequoia spinal instrumentation at l4-l5, partial reduction of spondylolisthesis at l4-l5. As per the op-notes,? I did foraminotomies of the adjacent nerve roots and i decompressed the lateral recesses proximal to this. At left l4-l5, i did find a moderate sized facet cyst. It did appear to have synovial fluid in it. On the mri from fall of 2009, i did not see any fluid in a left l4-l5 facet cyst. In addition, i did find evidence of a facet cyst at left l5. A wide foraminotomy was performed and i completely decompressed the left l5 nerve root. I decompressed the lateral recess proximal to this. I did feel that the patient's increased left leg pain was due to, at least in part, a left l4-l5 facet cyst. The patient also did have severe bony lateral recess stenosis at left l3-l4, and a large osteophyte did extend into the foramen adjacent to the left l4 nerve root. This was also decompressed. As mentioned, it was hard bony osteophyte. A wide foraminotomy of the left l4 nerve root was performed. I placed bmp and allograft cancellous bone chips. This was impacted. I then placed 3 tricortical allograft prostheses. These were impacted anterolaterally. Posterior to this, i placed autograft bone from the decompression that was meticulously cleaned. I also placed a small amount of allograft. I did not pack the interspace full and i allowed some room for subsidence. After final impaction, distraction was released and the prostheses were nicely compressed and stable. I then obtained a 35 mm rod. It was locked into position at right l4-l5. The construct was placed under a neutral position. I did do a partial reduction of the spondylolisthesis. I then placed bone screws into the pedicles of left l4 and left l5. They were placed in a similar fashion by drilling, probing and tapping. I used 5. 5 mm screws. Good fixation was obtained. I decorticated the transverse processes of l4 and l5. I resected the facet joint and decorticated this and decorticated the lamina of l4 and l5. I then did a posterolateral fusion. I placed allo graft chips, bone graft, and autograft bone from the decompression; that was meticulously cleaned. This was all placed posterolaterally and impacted. I also placed bone into the decorticated facet joint at left l4-l5. I placed a 35 mm rod. It was locked into position and placed under slight compression. The remaining bone graft was then placed posterolaterally and into the facet joint. After final impaction, i did place a transverse connector between the 2 rods. This was locked into position. Subsequent x-ray showed good position of the hardware and of the interbody prostheses. The wound was irrigated throughout the procedure with antibiotic irrigation. A medium hemovac drain was placed below the fascia. Fascia was then closed with #1 pds using both interrupted and running sutures. A watertight closure was obtained. Subcutaneous was closed with 0 pds to the deep layer, 2-0 vicryl to the superficial layer, and the skin was closed with 4-0 monocryl. Steri-strips were applied and dressing. The patient was sent to the recovery room in stable condition. Blood loss for this procedure was 150 cc. I was assisted throughout this procedure by (b)(6). This procedure was made more difficult due to the extensive scar tissue that was present from prior surgery. " post? Op diagnosis were: severe adhesions, l4-l5, facet fracture, right l4-l5, facet cyst left l4-l5. The patient's post-operative period had been marked by severe and chronic lower back pain, with pain and radiculopathy in her lower extremities; difficulty walking, sitting and standing; and occasional use of a walker to assist with ambulation. No intra-op complications were observed.
Patient Sequence No: 1, Text Type: D, B5


MAUDE Entry Details

Report Number1030489-2018-01440
MDR Report Key8029308
Report SourceCONSUMER
Date Received2018-11-01
Date of Report2018-11-01
Date Mfgr Received2018-10-02
Device Manufacturer Date2008-11-20
Date Added to Maude2018-11-01
Event Key0
Report Source CodeManufacturer report
Manufacturer LinkY
Number of Patients in Event0
Adverse Event Flag3
Product Problem Flag3
Reprocessed and Reused Flag3
Health Professional3
Initial Report to FDA3
Report to FDA3
Event Location3
Manufacturer ContactSTACIE ZIEMBA
Manufacturer Street1800 PYRAMID PLACE
Manufacturer CityMEMPHIS TN 38132
Manufacturer CountryUS
Manufacturer Postal38132
Manufacturer Phone9013963133
Manufacturer G1MEDTRONIC SOFAMOR DANEK USA, INC
Manufacturer Street4340 SWINEA RD
Manufacturer CityMEMPHIS TN 38118
Manufacturer CountryUS
Manufacturer Postal Code38118
Single Use3
Previous Use Code3
Event Type3
Type of Report3

Device Details

Brand NameINFUSE BONE GRAFT
Generic NameFILLER, RECOMBINANT HUMAN BONE MORPHOGENETIC PROTEIN, COLLAGEN SCAFFOLD WITH MET
Product CodeNEK
Date Received2018-11-01
Model NumberNA
Catalog Number7510050
Lot NumberM110814AAC
Device Expiration Date2010-03-31
OperatorHEALTH PROFESSIONAL
Device AvailabilityN
Device Eval'ed by MfgrN
Device Sequence No1
Device Event Key0
ManufacturerMEDTRONIC SOFAMOR DANEK USA, INC
Manufacturer Address4340 SWINEA RD MEMPHIS TN 38118 US 38118


Patients

Patient NumberTreatmentOutcomeDate
101. Other 2018-11-01

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