MAUDE Adverse Event Report: WRIGHTS LANE SYNTHES USA PRODUCTS LLC RIA 2 BONE HARVESTING KIT L520; ACCESSORIES, ARTHROSCOPIC

Model Number 03.404.000S

Device Problems Break (1069); Entrapment of Device (1212)

Patient Problem Foreign Body In Patient (2687)

Event Type  Injury  

Manufacturer Narrative

Additional procode: hto.Complainant part is not expected to be returned for manufacturer review/investigation.The investigation could not be completed; no conclusion could be drawn, as no product was received.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 Description

It was reported that on an unknown date during an femur graft procedure, three (3) ria 2 reamer heads broke in the patient.When retrieving the bone graft, the head became disconnected from the middle tip of the long assembly.Fragments remained in the patient.The procedure was successfully completed with an unknown amount of surgical delay.The patient outcome was unknown.This report is for one (1) ria 2 bone harvesting kit l520.This is report 4 of 4 for (b)(4).

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.H10 additional narrative: b2.H6: a device history record (dhr) review was conducted: part # 03.404.000s.Synthes lot # 76p1730.Supplier lot # 76p1730.Release to warehouse date: 17 nov 2020.Expiration date: 30 sep 2021.Supplier: (b)(4).No ncr's were generated during production.Review of the device history record(s) showed that there were no issues during the manufacture of this product, and any sub-components, 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.D7a: unknown.H4, h5.

• Brand Name: RIA 2 BONE HARVESTING KIT L520
• Type of Device: ACCESSORIES, ARTHROSCOPIC
• Manufacturer (Section D): WRIGHTS LANE SYNTHES USA PRODUCTS LLC; 1302 wrights lane east; west chester PA 19380
• MDR Report Key: 11148650
• MDR Text Key: 226086992
• Report Number: 2939274-2021-00165
• Device Sequence Number: 1
• Product Code: HRX
• UDI-Device Identifier: 10886982274236
• UDI-Public: (01)10886982274236
• Combination Product (y/n): N
• PMA/PMN Number: K111437
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative,health
• Type of Report: Initial,Followup
• Report Date: 12/14/2020

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
• Device Operator: Health Professional
• Device Expiration Date: 09/30/2021
• Device Model Number: 03.404.000S
• Device Catalogue Number: 03.404.000S
• Device Lot Number: 76P1730
• Was Device Available for Evaluation?: No
• Initial Date Manufacturer Received: 12/14/2020
• Initial Date FDA Received: 01/11/2021
• Supplement Dates Manufacturer Received: 02/12/2021
• Supplement Dates FDA Received: 02/12/2021
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1
• Treatment: 10.0MM REAMER HEAD FOR RIA 2 STERILE; 10.0MM REAMER HEAD FOR RIA 2 STERILE; 10.5MM REAMER HEAD FOR RIA 2 STERILE; 10.0MM REAMER HEAD FOR RIA 2 STERILE; 10.0MM REAMER HEAD FOR RIA 2 STERILE; 10.5MM REAMER HEAD FOR RIA 2 STERILE
• Patient Outcome(s): Required Intervention