BEUDAMED
    FDA Adverse Event Injury Summary report: N

    UNK - IMPLANT

    MDR report key: 23658646 · Received November 26, 2025

    Report

    Report Number
    1221934-2025-04545
    Event Type
    Injury
    Date Received
    November 26, 2025
    Date of Event
    January 1, 2025
    Report Date
    November 26, 2025
    Manufacturer
    DEPUY MITEK LLC US
    Product Code
    MAI
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    AS
    Reporter Occupation
    PHYSICIAN
    Health Professional
    Yes

    Narratives

    Additional Manufacturer Narrative · 0

    THIS REPORT IS BEING SUBMITTED PURSUANT TO THE PROVISIONS OF 21 CFR, PART 803. THIS REPORT MAY BE BASED ON INFORMATION WHICH HAS NOT BEEN INVESTIGATED OR VERIFIED PRIOR TO THE REQUIRED REPORTING DATE. THIS REPORT DOES NOT REFLECT A CONCLUSION BY DEPUY SYNTHES, OR ITS EMPLOYEES THAT THE REPORT CONSTITUTES AN ADMISSION THAT THE PRODUCT, DEPUY SYNTHES, OR ITS EMPLOYEES CAUSED OR CONTRIBUTED TO THE POTENTIAL EVENT DESCRIBED IN THIS REPORT. IF INFORMATION IS OBTAINED THAT WAS NOT AVAILABLE FOR THE INITIAL REPORT, A FOLLOW-UP REPORT WILL BE FILED AS APPROPRIATE. H11 ADDITIONAL NARRATIVE: THE COMPLAINT DEVICE WAS NOT RETURNED TO DEPUY SYNTHES, THEREFORE UNAVAILABLE FOR A PHYSICAL EVALUATION. GIVEN THAT NO LOT/SERIAL NUMBER WAS PROVIDED, A MANUFACTURING RECORD EVALUATION (MRE) REVIEW CANNOT BE PERFORMED. IF THE LOT/SERIAL NUMBER BECOMES AVAILABLE, THE MRE REVIEW WILL BE PERFORMED. BASED ON THE CURRENT AVAILABLE INFORMATION, WE CANNOT DETERMINE A ROOT CAUSE FOR THE REPORTED FAILURE. IF THE COMPLAINT DEVICE IS RECEIVED IN THE FUTURE, WE WILL REOPEN THE COMPLAINT AND PERFORM THE INVESTIGATION AS APPROPRIATE. IT HAS BEEN DETERMINED THAT NO CORRECTIVE AND/OR PREVENTATIVE ACTION IS PROPOSED AND THERE IS NO INDICATION THAT A DESIGN OR MANUFACTURING ISSUE HAS CAUSED THE REPORTED COMPLAINT CONDITION. AS PART OF DEPUY SYNTHES QUALITY PROCESS, ALL DEVICES ARE MANUFACTURED, INSPECTED, AND RELEASED TO APPROVED SPECIFICATIONS. ADDITIONAL MONITORING FOR ANY POTENTIAL SAFETY SIGNALS WILL BE CONDUCTED THROUGH COMPLAINT TRENDING AND OTHER POST-MARKET SAFETY SURVEILLANCE ACTIVITIES.

    Description of Event or Problem · 0

    THIS IS REPORT 2 OF 3 OF THIS CASE. NO MENTION OF EXPLANT IN OP REPORT, HOWEVER THERE IS A MENTION OF AN EXPLANTED 40MM LATARJET EXPERIENCE SCREW 288228 ON THE PROSTHESIS LABELS. THERE HAVE BEEN 2 KITS USED. THE FACT THAT THERE ARE 2 OTHER SCREWS (BOTH 36MM) INDICATES THAT THIS SCREW WAS INFACT REPLACED; I.E EXPLANTED. (B)(4), PAT. ID: (B)(6), 19 Y.O. MALE. SURG. INT., IMPLANT REMOVAL, SOFT TISSUE INJ. PEC: AE/NPP. NO MENTION OF EXPLANT IN OP REPORT, HOWEVER THERE IS A MENTION OF AN EXPLANTED 40MM LATARJET EXPERIENCE SCREW 288228 ON THE PROSTHESIS LABELS. THERE HAVE BEEN 2 KITS USED. THE FACT THAT THERE ARE 2 OTHER SCREWS (BOTH 36MM) INDICATES THAT THIS SCREW WAS IN FACT REPLACED; I.E EXPLANTED. THE DATE OF EVENT WAS UNKNOWN BUT WAS KNOWN TO HAVE OCCURRED IN 2025.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    2569891 UNK - IMPLANT UNK - IMPLANT MAI DEPUY MITEK LLC US

    Patients

    Seq Age Sex Outcome Treatment
    1 19 YR Male Required Intervention