MAUDE Adverse Event Report: BLUE BELT TECHNOLOGIES RI BONE PINS 4 MM X 127 MM QTY: 4; ORTHOPEDIC STEREOTAXIC INSTRUMENT

Model Number	ROB10010
Medical Device Problem Code	Material Twisted/Bent (2981)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	06/01/2021
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that, during set up for a cori-assisted ukr surgery, it was noticed that the ri bone pins 4 mm x 127 mm was significantly bent.The procedure was finished with a smith and nephew back up device without delays.The patient was not harmed.
Additional Manufacturer Narrative
H3, h6: the ri bone pins 4 mm x 127 mm, part number rob10010 intended for treatment was not returned for evaluation thus, a visual and functional evaluation could not be performed; thus, a relationship between the reported event and the device could not be determined.A review of manufacturing records indicate the device met all specifications upon release into distribution.A complaint history review for similar reported/confirmed complaints found related events.Although the reported problem was not confirmed, no reasonable contributing factors could be identified based on the received complaint information and investigation results.Although no further containment or corrective action is recommended or required at this time, all complaints are monitored and trended through post market surveillance activities.If the product associated with this event is returned or provided at a future date, this evaluation will be reopened for investigation.

• Brand Name: RI BONE PINS 4 MM X 127 MM QTY: 4
• Common Device Name: ORTHOPEDIC STEREOTAXIC INSTRUMENT
• Manufacturer (Section D): BLUE BELT TECHNOLOGIES; 2905 northwest blvd ste 40; plymouth MN 55441
• MDR Report Key: 12021804
• Report Number: 3010266064-2021-00455
• Device Sequence Number: 4543750
• Product Code: OLO
• UDI-Device Identifier: 00885556757277
• UDI-Public: 00885556757277
• Combination Product (Y/N): N
• Initial Reporter State: VA
• Initial Reporter Country: US
• PMA/510(K) Number: K201022
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 10/25/2021

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: ROB10010
• Device Catalogue Number: ROB10010
• Was Device Available for Evaluation?: Yes
• Initial Date Received by Manufacturer: 06/01/2021
• Supplement Date Received by Manufacturer: 10/22/2021
• Initial Report FDA Received Date: 06/17/2021
• Supplement Report FDA Received Date: 10/25/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1