MAUDE Adverse Event Report: MEDOS INTERNATIONAL SARL HD EPSCP,4.0,70,175,CW_STORZ; RIGID ENDOSCOPE

Model Number	242009
Medical Device Problem Code	Scratched Material (3020)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	12/30/2020
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Additional narrative: udi: (b)(4).Investigation summary: the complaint device was received at the service center and evaluated.It was reported that ¿during reprocessing, it was observed that the distal lens of the 70 degree scope was scratched.Upon investigation, it appears that an arthroscopic shaver must have made contact with the lens during surgery.¿.Per service reports, this complaint can be confirmed.During the service evaluation the following defects were identified: outer tube damaged, distal tip, distal tip damaged, shaver damage to distal tip, holes in distal tip fiber, fibers sunken in, image error, on camera image cloudy/blurred.Moisture in system moisture at distal end minor scratches on the unit.The defective parts were replaced to resolve the issues.After repair, the device was found to be working according to the specifications.The faulty parts were identified as the root cause for the device failure during the service evaluation.Manufacturing record evaluation is not required as the reported event is not associated with the manufacturing process and/or the potential cause of the defect cannot be associated to manufacturing.At this point in time, no corrective action is required, and no further action is warranted.Depuy mitek will continue to track any related complaints within this device family as a means of monitoring the extent with which this complaint is observed in the field.
Event or Problem Description
It was reported by the sales rep that during reprocessing for a hip procedure on (b)(6) 2020, it was observed that the distal lens on the endoscope device was scratched.During in-house engineering evaluation, it was determined that the image on the camera was cloudy and blurry.There were no adverse patient consequences reported.No additional information was provided.

• Brand Name: HD EPSCP,4.0,70,175,CW_STORZ
• Common Device Name: RIGID ENDOSCOPE
• Manufacturer (Section D): MEDOS INTERNATIONAL SARL; chemin blanc 38; le locle CH-24 00; SZ CH-2400
• MDR Report Key: 11752636
• Report Number: 1221934-2021-01401
• Device Sequence Number: 17025864
• Product Code: HRX
• UDI-Device Identifier: 10886705028788
• UDI-Public: 10886705028788
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K080560
• 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
• Type of Report: Initial
• Report Date (Section B): 04/29/2021

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: 242009
• Device Catalogue Number: 242009
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 02/09/2021
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 04/29/2021
• Initial Report FDA Received Date: 04/30/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1