MAUDE Adverse Event Report: DEPUY ORTHOPAEDICS INC US MI SCIATIC NERVE RETRACTOR; HIP INSTRUMENTS : RETRACTORS

Model Number	2598-07-150
Medical Device Problem Code	Crack (1135)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	04/06/2021
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Product complaint # (b)(4).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
It was reported that the sales consultant received a text message and a photo of one of their consignment instruments (sciatic nerve retractor) from one of their consignment trays (minimally invasive retractors).The blue plastic coating that covers the end of the retractor had cracked open along the edge of the retractor.It appears from the photo that the plastic coating is fully intact.The cracked coating was discovered during a routine inspection by spd personnel.
Additional Manufacturer Narrative
Product complaint # (b)(4).This report is being submitted pursuant to the provisions of 21 cfr, part 803.This report may be based on information which has not been investigated or verified prior to the required reporting date.This report does not reflect a conclusion by depuy synthes joint reconstruction, or its employees that the report constitutes an admission that the product, depuy synthes joint reconstruction, or its employees caused or contributed to the potential event described in this report.If information is obtained that was not available for the initial report, a follow-up report will be filed as appropriate.

• Brand Name: MI SCIATIC NERVE RETRACTOR
• Common Device Name: HIP INSTRUMENTS : RETRACTORS
• Manufacturer (Section D): DEPUY ORTHOPAEDICS INC US; 700 orthopaedic drive; warsaw IN 46581 0988
• MDR Report Key: 11700115
• Report Number: 1818910-2021-08384
• Device Sequence Number: 3436249
• Product Code: GAD
• UDI-Device Identifier: 10603295148128
• UDI-Public: 10603295148128
• Combination Product (Y/N): N
• Initial Reporter State: VA
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 04/06/2021

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: 2598-07-150
• Device Catalogue Number: 259807150
• Device Lot Number: HM0405
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 04/06/2021
• Supplement Date Received by Manufacturer: 05/20/2021; 05/06/2021
• Initial Report FDA Received Date: 04/21/2021
• Supplement Report FDA Received Date: 05/26/2021; 06/04/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1