MAUDE Adverse Event Report: CAYENNE MEDICAL SURELOCK 1.4MM FLEX ANCHOR; FASTENER, FIXATION, NONDEGRADABLE

Model Number	N/A
Medical Device Problem Code	Fracture (1260)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	09/14/2021
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
(b)(4).Multiple mdr reports were filed for this event, please see associated reports: 3006108336-2021-00047 and 3006108336-2021-00049.Concomitant medical products : unk arthrex scorpion, cm-9614f, surelock 1.4mm, flex anchor, unk lot.Report source : foreign : (b)(6).The device will not be returned for analysis, as the device was discarded; however, an investigation of the reported event is in progress.Once the investigation has been completed, a follow-up mdr will be submitted.
Event or Problem Description
It was reported that during the surgery, the suture was broken while the procedure of suture relay.No adverse events have been reported as a result of the malfunction.Attempts have been made and additional information on the reported event is unavailable at this time.
Additional Manufacturer Narrative
Upon completed investigation of this device, it is now determined to be not reportable.No serious injury or harm to the patient reported for this event or prior events with same or similar products.The initial report should be voided.
Event or Problem Description
Upon completed investigation of this device, it is now determined to be not reportable.No serious injury or harm to the patient reported for this event or prior events with same or similar products.The initial report should be voided.No further event information available at the time of this report.

• Brand Name: SURELOCK 1.4MM FLEX ANCHOR
• Common Device Name: FASTENER, FIXATION, NONDEGRADABLE
• Manufacturer (Section D): CAYENNE MEDICAL; 16597 n 92nd street; scottsdale AZ 85260
• Manufacturer (Section G): CAYENNE MEDICAL; 16597 n 92nd street; scottsdale AZ 85260
• Manufacturer Contact: shima hashemian ; 16597 n 92nd street; scottsdale, AZ 85260 ; 4805023661
• MDR Report Key: 12689002
• Report Number: 3006108336-2021-00048
• Device Sequence Number: 11832719
• Product Code: MBI
• UDI-Device Identifier: 00887868270482
• UDI-Public: (01)00887868270482(17)231203(10)78584-1
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: K132867
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Foreign,Health Professional,Company Representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 11/18/2021

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 Expiration Date: 12/03/2023
• Device Model Number: N/A
• Device Catalogue Number: CM-9614F
• Device Lot Number: 78584-1
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 09/28/2021
• Supplement Date Received by Manufacturer: 11/12/2021
• Initial Report FDA Received Date: 10/25/2021
• Supplement Report FDA Received Date: 11/19/2021
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 12/04/2020
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• If action reported to FDA under 21 USC 360i(g), list FDA-assigned Recall Number or include a statement: N/A
• Patient Sequence Number: 1
• Patient Sex: Unknown