MAUDE Adverse Event Report: SMITH & NEPHEW, INC. 4KO VIDEOARTHROSCOPE AC 4X70X160MM RND

Model Number	72205150
Medical Device Problem Code	Crack (1135)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
(b)(4).
Event or Problem Description
It was reported that the videoarthroscope was cracked at the tip of the scope where the distal lens resides.The incident occurred before the procedure.There was no delay and a backup device was available to complete the procedure with no complications reported.
Additional Manufacturer Narrative
H10, h3, h6: the reported device, intended for use in treatment, was received for evaluation there was a relationship found between the returned device and the reported incident.A visual inspection found distal tip and fiber damage and scratched distal lens.A review of device records showed there were no indications to suggest that the product did not meet manufacturing specification upon release for distribution.A complaint history review concluded this was a repeat issue.The complaint was confirmed.Factors that could have contributed to the reported event include an impact event inconsistent with normal use.Internal complaint reference: (b)(4).

• Brand Name: 4KO VIDEOARTHROSCOPE AC 4X70X160MM RND
• Common Device Name: ARTHROSCOPE
• Manufacturer (Section D): SMITH & NEPHEW, INC.; 150 minuteman road; andover MA 01810
• MDR Report Key: 11809474
• Report Number: 3003604053-2021-00183
• Device Sequence Number: 3909919
• Product Code: HRX
• UDI-Device Identifier: 00885556736050
• UDI-Public: 00885556736050
• Combination Product (Y/N): N
• Initial Reporter State: CA
• Initial Reporter Country: US
• PMA/510(K) Number: K201349
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,user f
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 06/07/2021

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: 72205150
• Device Catalogue Number: 72205150
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 04/22/2021
• Initial Date Received by Manufacturer: 04/20/2021
• Supplement Date Received by Manufacturer: 06/04/2021
• Initial Report FDA Received Date: 05/11/2021
• Supplement Report FDA Received Date: 06/07/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1