MAUDE Adverse Event Report: ARTHREX, INC. STOPCOCK,SINGLE,SPARE,FOR SYNERGY SHEATH; ACCESSORIES, ARTHROSCOPIC

Model Number	STOPCOCK,SINGLE,SPARE,FOR SYNERGY SHEATH
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	02/18/2021
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The contribution of the device to the reported event could not be determined as the device was not returned for evaluation.The root cause of the event could not be determined from the information available and without device evaluation.
Event or Problem Description
It was reported that the surgeon fount something that may look like small red pieces of plastic in the knee joint during knee arthroscopy.They have examined everything, the only red is the red gasket of ar-3370-0001.The pieces were removed from patient.No harm or adverse event for patient, operator or third party was reported.The surgery was finished successfully with the same device was used anyway.It was not necessary to switch the surgical technique or do a second surgery.
Additional Manufacturer Narrative
Complaint confirmed.The returned piece appears to be part of the o-ring, from the the ar-3370-0001 stopcock.Visual and function evaluation of the device could not be performed, since the device was not returned for further evaluation.The cause is undetermined.

• Brand Name: STOPCOCK,SINGLE,SPARE,FOR SYNERGY SHEATH
• Common Device Name: ACCESSORIES, ARTHROSCOPIC
• Manufacturer (Section D): ARTHREX, INC.; 1370 creekside boulevard; naples FL 34108 1945
• MDR Report Key: 11436034
• Report Number: 1220246-2021-02677
• Device Sequence Number: 11477326
• Product Code: NBH
• UDI-Device Identifier: 00888867029880
• UDI-Public: 00888867029880
• Combination Product (Y/N): N
• Initial Reporter Country: NO
• PMA/510(K) Number: EXEMPT
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Administrator/Supervisor
• Type of Report: Initial,Followup
• Report Date (Section B): 06/25/2021

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: STOPCOCK,SINGLE,SPARE,FOR SYNERGY SHEATH
• Device Catalogue Number: AR-3370-0001
• Device Lot Number: 1586902
• Was Device Available for Evaluation?: Yes
• Initial Date Received by Manufacturer: 02/18/2021
• Supplement Date Received by Manufacturer: 02/18/2021
• Initial Report FDA Received Date: 03/08/2021
• Supplement Report FDA Received Date: 06/25/2021
• Patient Sequence Number: 1