MAUDE Adverse Event Report: WRIGHTS LANE SYNTHES USA PRODUCTS LLC MATRIX SIMPLE PERSUADER- STANDARD; MISC ORTHO SURGICAL INSTR

Model Number	03.632.009
Medical Device Problem Code	Compatibility Problem (2960)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	11/01/2020
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Complainant part is expected to be returned for manufacturer review/investigation, but has yet to be received.Without a lot number the device history records review could not be completed.Product was not returned.Based on the information available, it has been determined that no corrective and/or preventative action is proposed.This complaint will be accounted for and monitored via post market surveillance activities.If additional information is made available, the investigation will be updated as applicable.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
Device report from synthes reports an event in (b)(6) as follows: it was reported that on (b)(6) 2020 during a matrix mis procedure, several instruments were damaged.Two (2) rod introducers could no longer properly hold the rods making it difficult for patient insertion.The screwdriver shaft was stripped at the distal end tip.The rod persuader could no longer hold its position once engaged.There was no surgical delay.There was no patient consequence.The procedure outcome is unknown.This report is for one (1) matrix simple persuader- standard.This is report 4 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.H3, h6: investigation summary: flow: device interaction/ functional.Visual inspection: the rod persuader std f/matrix 5.5 (product code: 03.632.009 , lot number: t972130) at uscq.Upon visual inspection there were no defects identified on the device but the ratchet release trigger was observed to release on its own sometimes during the usage of the handle.Functional test: the handle was closed and released several times to check the locking feature of the device.The ratchet release trigger was releasing early on its own few times.Complaint can be replicated with the returned device.Dimensional inspection: no dimensional inspection performed due to confirmed post manufacturing damage.Complaint was confirmed.Conclusion: the complaint condition is confirmed for the rod persuader std f/matrix 5.5 (product code: 03.632.009 , lot number: t972130).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 history lot: part number:03.632.009.Synthes lot number: t972130.Supplier lot number: n/a.Release to warehouse date: feb 01, 2012.Expiration date: jan 27, 2032.Lot quantity: 32.No ncrs were generated during production.Device history review.Review of the device history record showed that there were no issues during the manufacture of this product, and any subcomponents, which would contribute to this complaint condition.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: MATRIX SIMPLE PERSUADER- STANDARD
• Common Device Name: MISC ORTHO SURGICAL INSTR
• Manufacturer (Section D): WRIGHTS LANE SYNTHES USA PRODUCTS LLC; 1302 wrights lane east; west chester PA 19380
• MDR Report Key: 10923271
• Report Number: 2939274-2020-05367
• Device Sequence Number: 19364848
• Product Code: LXH
• UDI-Device Identifier: 10705034718743
• UDI-Public: (01)10705034718743
• Combination Product (Y/N): N
• Initial Reporter Country: CA
• PMA/510(K) Number: EXEMPT
• 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: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 11/01/2020

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: 03.632.009
• Device Catalogue Number: 03.632.009
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 12/23/2020
• Initial Date Received by Manufacturer: 11/01/2020
• Supplement Date Received by Manufacturer: 12/29/2020
• Initial Report FDA Received Date: 11/30/2020
• Supplement Report FDA Received Date: 01/06/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: ROD HOLDER; ROD HOLDER; SCRDRIVERSHAFT T25 CANN LONG; ROD HOLDER; ROD HOLDER; SCRDRIVERSHAFT T25 CANN LONG