MAUDE Adverse Event Report: ARTHREX, INC. BC, CORKSCREW FT, TRI-PLAY, 4.75MM; FASTENER, FIXATION, BIODEGRADABLE, SOFT TISSUE

Model Number	BC, CORKSCREW FT, TRI-PLAY, 4.75MM
Health Effect - Clinical Code	Foreign Body In Patient (2687)
Date of Event	04/25/2022
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 04/27/2022, it was reported by a sales representative via phone that a ar-1927bcf-475 suture anchor broke.This occurred on 04/25/2022 during a rotator cuff repair when the anchor was implanted and backed out.When the anchor backed out it was discovered that it had broke inside the patient.The broken fragment was removed, and the case was completed using a larger anchor that worked fine.There was no patient effect reported.

• Brand Name: BC, CORKSCREW FT, TRI-PLAY, 4.75MM
• Common Device Name: FASTENER, FIXATION, BIODEGRADABLE, SOFT TISSUE
• 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: 14407051
• Report Number: 1220246-2022-04903
• Device Sequence Number: 4909361
• Product Code: MAI
• UDI-Device Identifier: 00888867238541
• UDI-Public: 00888867238541
• Combination Product (Y/N): N
• Initial Reporter State: MO
• Initial Reporter Country: US
• PMA/510(K) Number: K173788
• 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
• Report Date (Section B): 05/16/2022

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 Expiration Date: 09/30/2025
• Device Model Number: BC, CORKSCREW FT, TRI-PLAY, 4.75MM
• Device Catalogue Number: AR-1927BCF-475
• Device Lot Number: 14292013
• Was Device Available for Evaluation?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 04/27/2022
• Initial Report FDA Received Date: 05/16/2022
• Date Device Manufactured: 10/08/2021
• Is the Device Labeled for Single Use? (Y/N): Yes
• Usage of Device: Initial
• Patient Sequence Number: 1
• Patient Sex: Unknown