MAUDE Adverse Event Report: WRIGHTS LANE SYNTHES USA PRODUCTS LLC MATRIXMANDIBLE THREADED TROCAR DRILL GUIDE FOR 397.213

Model Number	03.503.047
Medical Device Problem Codes	Break (1069); Device-Device Incompatibility (2919)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The device was received, the investigation is in progress, no conclusion could be drawn at the time of filing this report.Device was used for treatment, not diagnosis.If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.
Event or Problem Description
It was reported that on (b)(6) 2020, the two (2) trays; matrix mandible and matrix midface tray were inspected because the trays had fallen from a shelf in the sterile processing department (spd).Several parts were noted to be damaged in the tray.One (1) bone reduction forcep had a broken fine tip, one (1) screwdriver handle was broken end cap is missing, one (1) matrixmandible drill guide broken tip damage on which the drill bit would not easily sliding through, and one (1) t-handle was broken slide is very loose.There was no patient involvement.This is report 3 of 4 for (b)(4).
Additional Manufacturer Narrative
Depuy synthes is submitting this report pursuant to the provisions of 21 cfr, part 803.This report may be based on information which depuy synthes has not been able to investigate or verify prior to the required reporting date.This report does not reflect a conclusion by fda, depuy synthes or its employees that the report constitutes an admission that the device, depuy synthes, or its employees caused or contributed to the potential event described in this report.If the information is unknown, not available or does not apply, the section/field of the form is left blank.H10 additional narrative: h3, h4, h6: part: 03.503.047.Lot: 8899650.Manufacturing site: (b)(4).Release to warehouse date: (b)(6) 2014.A manufacturing record evaluation was performed for the finished device lot number, and no non-conformities were identified.Visual inspection: the matrixmandible threaded trocar drill guide for 397.213 (p/n: 03.503.047, lot number: 8899650) was received at us customer quality (cq).Upon visual inspection, the distal threads are broken off.Device failure/defect identified? yes.Functional test: a functional assessment was unable to be performed on the complaint device due to lack of mating devices.However, the damaged threads would allow the condition of unable to assemble to be replicated.Dimensional inspection: no dimensional inspection was performed due to post-manufacturing damage.Document/specification review: current and manufactured were reviewed.No design issues or discrepancies were identified.Complaint confirmed? yes.Investigation conclusion: this complaint is confirmed as the distal threads are broken off, causing the unable to assemble condition.No definitive root cause could be determined based on the provided information.No new, unique or different patient harms were identified as a result of this evaluation.There was no indication that a design or manufacturing issue contributed to the complaint.No design issues were observed during the document/specification review.Based on the investigation findings, it has been determined that no corrective and/or preventative action is proposed.Additional monitoring for any potential safety signals will be conducted through complaint trending and other post market safety surveillance activities.Device was used for treatment, not diagnosis.If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.

• Brand Name: MATRIXMANDIBLE THREADED TROCAR DRILL GUIDE FOR 397.213
• Common Device Name: GUIDE
• Manufacturer (Section D): WRIGHTS LANE SYNTHES USA PRODUCTS LLC; 1302 wrights lane east; west chester PA 19380
• MDR Report Key: 10020834
• Report Number: 2939274-2020-02219
• Device Sequence Number: 2813442
• Product Code: FZX
• UDI-Device Identifier: 10887587011738
• UDI-Public: (01)10887587011738
• Combination Product (Y/N): N
• Initial Reporter State: NY
• Initial Reporter Country: US
• PMA/510(K) Number: EXEMPT
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 04/20/2020

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Model Number: 03.503.047
• Device Catalogue Number: 03.503.047
• Device Lot Number: 8899650
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 04/29/2020
• Initial Date Received by Manufacturer: 04/20/2020
• Supplement Date Received by Manufacturer: 05/08/2020
• Initial Report FDA Received Date: 05/04/2020
• Supplement Report FDA Received Date: 05/19/2020
• Patient Sequence Number: 1