MAUDE Adverse Event Report: SMITH & NEPHEW, INC. UNKN ZUK UNI KNEE INSTR; TEMPLATE

Model Number	00584202408
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	01/11/2021
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
(b)(4).
Event or Problem Description
It was reported that during total knee arthroplasty poly trial broke in half while trialing.The procedure was finished using a smith and nephew back up device.No delay reported.
Additional Manufacturer Narrative
The device, used in treatment, was not returned for evaluation and the reported event could not be confirmed.At this time, we have no reason to suspect that the product failed to meet any product specifications at the time of manufacture.This device is a reusable instrument that can be exposed to numerous surgeries.Damage from prolonged use, misuse or rough handling are likely probable causes of the reported event.We recommend that all reusable instruments be routinely inspected for wear and damage and replaced as necessary.Based on this investigation, the need for corrective action is not indicated.Without the return of the actual product involved, our investigation could not proceed.Should the device or additional information be received, the complaint will be reopened.No further investigation is warranted for this complaint; however, we will continue to monitor for future complaints and investigate as necessary.We consider this investigation closed.
Event or Problem Description
It was reported that during total knee arthroplasty an unknown trial broke in half while trialing.The procedure was finished using a smith and nephew back up device.No delay or harm to the patient reported.

• Brand Name: UNKN ZUK UNI KNEE INSTR
• Common Device Name: TEMPLATE
• Manufacturer (Section D): SMITH & NEPHEW, INC.; 1450 brooks rd.; memphis TN 38116
• MDR Report Key: 11256344
• Report Number: 1020279-2021-00783
• Device Sequence Number: 3848503
• Product Code: HWT
• UDI-Device Identifier: 00885556620151
• UDI-Public: 00885556620151
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K033363
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 08/24/2021

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: 00584202408
• Device Catalogue Number: UNKN01400116
• Device Lot Number: UNKNOWN
• Initial Date Received by Manufacturer: 01/11/2021
• Supplement Date Received by Manufacturer: 08/24/2021
• Initial Report FDA Received Date: 01/30/2021
• Supplement Report FDA Received Date: 08/24/2021
• 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: Required Intervention