MAUDE Adverse Event Report: ARTHREX, INC. UNIVERS REVS STEM/CUP INSERTR IMPACTOR; INSTRUMENT, MANUAL, SURGICAL, GENERAL USE

Model Number	UNIVERS REVS STEM/CUP INSERTR IMPACTOR
Health Effect - Clinical Code	Insufficient Information (4580)
Date of Event	05/18/2021
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.If the device becomes available for evaluation, a follow-up report will be submitted.
Event or Problem Description
It was reported that during a nano-ccu/nano-sport surgery the screw broke intra-operatively.The surgeon was able to retrieve the broken part out of the patient.There was no harm for patient, operator or third party reported.The surgery was finished successfully with a new device with the same part number.It was not necessary to switch the surgical technique or do a second surgery.
Additional Manufacturer Narrative
Complaint confirmed the tip of the threaded pin broke off.The relevant critical dimension was found to meet specifications.The cause of the breakage is undetermined.The device was also found to be corroded, the cause of which is undetermined as well.

• Brand Name: UNIVERS REVS STEM/CUP INSERTR IMPACTOR
• Common Device Name: INSTRUMENT, MANUAL, SURGICAL, GENERAL USE
• Manufacturer (Section D): ARTHREX, INC.; 1370 creekside boulevard; naples FL 34108 1945
• MDR Report Key: 11946583
• Report Number: 1220246-2021-03204
• Device Sequence Number: 19923176
• Product Code: MDM
• UDI-Device Identifier: 00888867061828
• UDI-Public: 00888867061828
• Combination Product (Y/N): N
• Initial Reporter Country: GM
• PMA/510(K) Number: EXEMPT
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: foreign,health professional,u
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 10/20/2021

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: UNIVERS REVS STEM/CUP INSERTR IMPACTOR
• Device Catalogue Number: AR-9511
• Device Lot Number: 121432
• Was Device Available for Evaluation?: Yes
• Initial Date Received by Manufacturer: 05/18/2021
• Supplement Date Received by Manufacturer: 05/18/2021
• Initial Report FDA Received Date: 06/07/2021
• Supplement Report FDA Received Date: 10/20/2021
• Patient Sequence Number: 1