MAUDE MDR 8074698

MDR report key
8074698
Report number
1526439-2018-51069
Event key
0
Event type
3
Date of event
2018-01-01
Date received
2018-11-15
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
1
Health professional
3
Initial report to FDA
3
Event location
3

Manufacturer Contact#

Contact
KARA DITTY-BOVARD
Address
325 PARAMOUNT DRIVE RAYNHAM MA 02767 US
Phone
610-610-6103
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1MIS TI CFX FEN POLY 7X45BONE CEMENT, POSTERIOR SCREW AUGMENTATIONMEDOS INTERNATIONAL SàRL CHPML186727745186727745131106Y R

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12018-11-1501. R

Event Narratives#

N

Patient 1

(B)(4). 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.

D

Patient 1

IT WAS REPORTED: BROKEN ROD AT L5 LEFT / CAUSED THE REVISION (REVISION CASE TOOK PLACE (B)(6) 2018). LOOSE PEDICLE SCREW L5 RIGHT / CAUSED THE REVISION (REVISION CASE TOOK PLACE (B)(6) 2018). BROKEN PEDICLE SCREW S1 RIGHT / CAUSED THE REVISION (REVISION CASE TOOK PLACE (B)(6) 2018). BROKEN ILIAC SCREW RIGHT / CAUSED THE REVISION (REVISION CASE TOOK PLACE (B)(6) 2018). LOOSE PEDICLE SCREW L5 LEFT / CAUSED THE REVISION (REVISION CASE TOOK PLACE (B)(6) 2018). BROKEN EXPEDIUM POLYAXIAL SCREWDRIVER / OCCURRED DURING THE REVISION SURGERY (B)(6) 2018. BROKEN POWER EXPEDIUM / OCCURRED DURING THE REVISION SURGERY (B)(6) 2018.