MAUDE Adverse Event Report: ARTHREX, INC. INSERTION GUIDE ASSEMBLY; ORTHOPEDIC MANUAL SURGICAL INSTRUMENT

Model Number	INSERTION GUIDE ASSEMBLY
Health Effect - Clinical Code	Insufficient Information (4580)
Date of Event	04/05/2022
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
On 4/6/2022, it was reported by a sales representative via email that an ar-8973-14 implant insertion guide broke off in patient and was removed.This was discovered during an orif ankle procedure on (b)(6) 2022.Case was completed without further issues.
Additional Manufacturer Narrative
The complaint is confirmed based on the customer-provided photos, which display the broken guide.However, without receipt of the device for physical evaluation, the cause remains undetermined.No change in harm was identified.

• Brand Name: INSERTION GUIDE ASSEMBLY
• Common Device Name: ORTHOPEDIC MANUAL SURGICAL INSTRUMENT
• Manufacturer (Section D): ARTHREX, INC.; 1370 creekside boulevard; naples FL 34108 1945
• Manufacturer (Section G): ARTHREX, INC.; 1370 creekside boulevard; naples FL 34108 1945
• Manufacturer Contact: vik bajnath ; 8009337001
• MDR Report Key: 14192796
• Report Number: 1220246-2022-04777
• Device Sequence Number: 14696247
• Product Code: LXH
• UDI-Device Identifier: 00888867302730
• UDI-Public: 00888867302730
• Combination Product (Y/N): N
• Initial Reporter State: TX
• Initial Reporter Country: US
• PMA/510(K) Number: EXEMPT
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Distributor
• Initial Reporter Occupation: Administrator/Supervisor
• Type of Report: Initial,Followup
• Report Date (Section B): 05/03/2022

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: INSERTION GUIDE ASSEMBLY
• Device Catalogue Number: AR-8973-14
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 04/06/2022
• Supplement Date Received by Manufacturer: 04/06/2022
• Initial Report FDA Received Date: 04/25/2022
• Supplement Report FDA Received Date: 05/04/2022
• Is the Device Labeled for Single Use? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Patient Sex: Unknown