MAUDE Adverse Event Report: DEPUY MITEK LLC US FASTIN RC 5.0 ETHIBOND W/NDLS; SOFT-TISSUE ANCHOR, NON-BIOABSORBABLE

Model Number	222722
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	09/21/2020
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Product complaint #: (b)(4).To date the device has not been returned.If the device or further details are received at a later date a supplemental medwatch will be sent.Udi: (b)(4).
Event or Problem Description
It was reported that during the unknown surgery, when removed the shaft, noted the anchor was broken and the suture was broken as the photo shows.All the pieces were removed from the patient.Another device was used to complete the surgery.There were no adverse consequences to the patient.No additional information could be provided.
Additional Manufacturer Narrative
This report is being submitted in pursuant to the provisions of 21 cfr, part 803.This report may be based on information which has not been able to investigate or verify prior to the required reporting date.This report does not reflect a conclusion by mitek or its employees that the report constitutes an admission that the device, mitek, 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 medwatch, a follow-up medwatch will be filed as appropriate.H10 additional narrative: d10, h3, h6: the actual device has been returned and is currently pending evaluation.Once reliability engineering evaluates the device, a supplemental medwatch report will be sent accordingly.If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.
Additional Manufacturer Narrative
This report is being submitted in pursuant to the provisions of 21 cfr, part 803.This report may be based on information which has not been able to investigate or verify prior to the required reporting date.This report does not reflect a conclusion by mitek or its employees that the report constitutes an admission that the device, mitek, 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 medwatch, a follow-up medwatch will be filed as appropriate.Investigation summary according to the information provided, it was reported that during the unknown surgery, when removed the shaft, noted the anchor was broken and the suture was broken.The complaint device was received and evaluated.Visual observations and visual inspection on the pictures provided confirm that the anchor was detached from the shaft inserter.In addition, the anchor presented tissue debris.When observed the anchor under magnification, no structural anomalies could be noted.In another hand, the sutures, were presented biological residues and were slight frayed in the distal and the suture card was missing.The complaint can be confirmed.The possible root cause for the reported failure can be attributed to excessive force applied and levering during insertion.However, this cannot be conclusive determined.A manufacturing record evaluation was performed for the finished device lot number:6l84310, and no non-conformances were identified.At this point in time, no corrective action is required and no further action is warranted.However, depuy synthes mitek will continue to track any related complaints within this device family as a means of monitoring the extent with which this complaint is observed in the field.

• Brand Name: FASTIN RC 5.0 ETHIBOND W/NDLS
• Common Device Name: SOFT-TISSUE ANCHOR, NON-BIOABSORBABLE
• Manufacturer (Section D): DEPUY MITEK LLC US; 325 paramount drive; raynham MA 02767
• MDR Report Key: 10638588
• Report Number: 1221934-2020-02891
• Device Sequence Number: 3054627
• Product Code: HWC
• UDI-Device Identifier: 10886705008247
• UDI-Public: 10886705008247
• Combination Product (Y/N): N
• Initial Reporter Country: CH
• PMA/510(K) Number: K060664
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup,Followup,Followup
• Report Date (Section B): 09/21/2020

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 Expiration Date: 02/28/2023
• Device Model Number: 222722
• Device Catalogue Number: 222722
• Device Lot Number: 6L84310
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 11/20/2020
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 09/21/2020
• Supplement Date Received by Manufacturer: 11/20/2020; 11/24/2020; 12/15/2020
• Initial Report FDA Received Date: 10/06/2020
• Supplement Report FDA Received Date: 11/23/2020; 11/25/2020; 12/17/2020
• Patient Sequence Number: 1