MAUDE Adverse Event Report: RESOLVE SURGICAL TECHNOLOGIES 1.7 CABLE LCK PIST GRIP CBL TENSIONER; WIRE CUTTER

Model Number	03.221.017
Medical Device Problem Code	Device-Device Incompatibility (2919)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	03/22/2022
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Depuy synthes is submitting this report pursuant to the provisions of 21 cfr, part 803.This report may be based on information which depuy synthes has not been able to investigate or verify prior to the required reporting date.This report does not reflect a conclusion by fda, depuy synthes or its employees that the report constitutes an admission that the device, depuy synthes, or its employees caused or contributed to the potential event described in this report.If the information is unknown, not available or does not apply, the section/field of the form is left blank.Device available for evaluation: complainant part is expected to be returned for manufacturer review/investigation, but has yet to be received.Reporter is a j&j sales representative.Device evaluated by mfr: the investigation could not be completed; no conclusion could be drawn, as no product was received.Investigation summary: product was not returned.Based on the information available, it has been determined that no corrective and preventative action is proposed.This complaint will be accounted for and monitored via post market surveillance activities.If additional information is made available, the investigation will be updated as applicable a manufacturing record evaluation was performed for the part # 03.221.017, lot # p364223 and no non-conformances were identified.
Event or Problem Description
Device report from depuy synthes reports an event in united kingdom as follows: this is report 2 of 2 for (b)(4).It was reported by the sales rep in united kingdom that during a periprosthetic fracture fixation procedure on (b)(6) 2022, it was observed that the surgeon was not able to release the gun device from the cable device after tensioning.According to the report, it took the surgeon a few tries to be able to release it.At the next cable insertion, he was not able to pass the new wire through the device.Another like devices were used to complete the procedure with an unspecified delay.There were no adverse patient consequences reported.No additional information was provided.This report is for one (1) 1.7 cable lck pist grip cbl tensioner device.This complain involves two(2) devices.

• Brand Name: 1.7 CABLE LCK PIST GRIP CBL TENSIONER
• Common Device Name: WIRE CUTTER
• Manufacturer (Section D): RESOLVE SURGICAL TECHNOLOGIES; 375 river park circle; marquette MI 49855
• Manufacturer Contact: brandee sandy ; 375 river park circle; marquette, MI 49855
• MDR Report Key: 14137925
• Report Number: 1833824-2022-00033
• Device Sequence Number: 11758879
• Product Code: LXH
• UDI-Device Identifier: 10886982076779
• UDI-Public: 10886982076779
• Combination Product (Y/N): N
• Initial Reporter Country: UK
• PMA/510(K) Number: EXEMPT
• 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,User Facility,Company Representative
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial

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: 03.221.017
• Device Catalogue Number: 03.221.017
• Device Lot Number: P364223
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 03/22/2022
• Initial Report FDA Received Date: 04/18/2022
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 08/13/2020
• Is the Device Labeled for Single Use? (Y/N): No
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Unknown
• Patient Sequence Number: 1
• Patient Sex: Unknown