MAUDE Adverse Event Report: ARTHREX, INC. ROTATION LASSO, 90 DEG TIP; ORTHOPEDIC MANUAL SURGICAL INSTRUMENT

Model Number	ROTATION LASSO, 90 DEG TIP
Health Effect - Clinical Code	Insufficient Information (4580)
Date of Event	05/13/2022
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 5/16/2022, it was reported by an arthrex employee via email that an ar-6065-90 rotation lasso wire tip broke.A new product was used to complete the case.This was discovered during a procedure on (b)(6) 2022.

• Brand Name: ROTATION LASSO, 90 DEG TIP
• 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: 14548270
• Report Number: 1220246-2022-05000
• Device Sequence Number: 5245939
• Product Code: LXH
• UDI-Device Identifier: 00888867288652
• UDI-Public: 00888867288652
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: EXEMPT
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Foreign,Company Representative
• Initial Reporter Occupation: Administrator/Supervisor
• Type of Report: Initial
• Report Date (Section B): 05/31/2022

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: 10/31/2025
• Device Model Number: ROTATION LASSO, 90 DEG TIP
• Device Catalogue Number: AR-6065-90
• Device Lot Number: 0296107300
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 05/13/2022
• Initial Report FDA Received Date: 05/31/2022
• Date Device Manufactured: 11/01/2020
• Is the Device Labeled for Single Use? (Y/N): Yes
• Usage of Device: Initial
• Patient Sequence Number: 1
• Patient Sex: Unknown