MAUDE Adverse Event Report: STRYKER ENDOSCOPY-SAN JOSE AIR MENISCUS SYSTEM, CURVED; SUTURE, NONABSORBABLE, SYNTHETIC, POLYETHYLENE

Model Number	4720
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	11/24/2020
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Additional information will be provided once the investigation has been completed.The device manufacturer date is not known at this time.However, should it become available it will be provided in future reports.
Event or Problem Description
It was reported that the anchor broke during the procedure.It was not able to be confirmed that all pieces were removed.
Additional Manufacturer Narrative
This complaint investigation was closed based on the device not received, therefore the reported failure mode was not confirmed.In the event that the device is received, the complaint will be reopened and the investigation will be updated with new results.Alleged failure: anchor broken.Probable root cause: design.Inadequate raw material specification (needle or depth indicator).Needle tube thickness too thin or too thick.Suture does not have adequate working length.Inadequate handle assembly design.Inadequate raw material.Depth indicator thickness too thin or too thick process.Depth indicator not manufactured to specification.Needle or implant body not manufactured to specification.Dimple process on needle not manufactured to specification.Inadequate design of needle/depth indicator to create interference to retain/remove depth indicator.Stiffener not manufactured to specification application.User intentionally bends/forces instrument.Incision too small.Inadequate or improper visualization.User not familiar with device use.User does not use sled or other technique to prevent catching on soft tissue.The reported failure mode will be monitored for future reoccurrence.Manufacturing date is unknown.
Event or Problem Description
It was reported that the anchor broke during the procedure.It was not able to be confirmed that all pieces were removed.

• Brand Name: AIR MENISCUS SYSTEM, CURVED
• Common Device Name: SUTURE, NONABSORBABLE, SYNTHETIC, POLYETHYLENE
• Manufacturer (Section D): STRYKER ENDOSCOPY-SAN JOSE; 5900 optical court; san jose CA 95138
• MDR Report Key: 11016381
• Report Number: 0002936485-2020-00532
• Device Sequence Number: 14576733
• Product Code: GAT
• UDI-Device Identifier: 07613327375404
• UDI-Public: 07613327375404
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: K153087
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 01/29/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Model Number: 4720
• Device Catalogue Number: 4720
• Device Lot Number: 7002820
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 11/25/2020
• Supplement Date Received by Manufacturer: 11/25/2020
• Initial Report FDA Received Date: 12/16/2020
• Supplement Report FDA Received Date: 01/29/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Other