MAUDE Adverse Event Report: STRYKER ENDOSCOPY-SAN JOSE PKG,, ASSY., PEEK SOFT EYELET RC ANCHOR, 5.5MM; SCREW, FIXATION, BONE

Catalog Number	3910-400-010
Medical Device Problem Code	Material Fragmentation (1261)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	06/29/2023
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Additional information will be provided once the investigation has been completed.
Event or Problem Description
It was reported that the anchor broke during procedure.All pieces were retrieved.
Additional Manufacturer Narrative
This complaint investigation was closed based on the device not received, therefore the reported failure mode was not confirmed.In the event that the device is received, the complaint will be reopened and the investigation will be updated with new results.Alleged failure: broken during surgery.Probable root cause: design: anchor material/design too weak process; anchor not manufactured to specification.Application: excessive force.The reported failure mode will be monitored for future reoccurrence.
Event or Problem Description
It was reported that the anchor broke during procedure.All pieces were retrieved.

• Brand Name: PKG,, ASSY., PEEK SOFT EYELET RC ANCHOR, 5.5MM
• Common Device Name: SCREW, FIXATION, BONE
• Manufacturer (Section D): STRYKER ENDOSCOPY-SAN JOSE; 5900 optical court; san jose CA 95138
• Manufacturer (Section G): STRYKER ENDOSCOPY-SAN JOSE; 5900 optical court; san jose CA 95138
• Manufacturer Contact: vijay menon ; 5900 optical court; san jose, CA 95138 ; 4087542000
• MDR Report Key: 17552569
• Report Number: 0002936485-2023-00807
• Device Sequence Number: 15167261
• Product Code: HWC
• UDI-Device Identifier: 07613154644568
• UDI-Public: 07613154644568
• Combination Product (Y/N): N
• Initial Reporter Country: IN
• PMA/510(K) Number: K071157
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Health Professional
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 02/16/2024

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 Catalogue Number: 3910-400-010
• Device Lot Number: 23016AE2
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 07/20/2023
• Supplement Date Received by Manufacturer: 07/20/2023
• Initial Report FDA Received Date: 08/15/2023
• Supplement Report FDA Received Date: 02/16/2024
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 01/16/2023
• 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
• Patient Sequence Number: 1
• Patient Sex: Unknown