MAUDE Adverse Event Report: MEDLINE INDUSTRIES, LP; KNEE ARTHROSCOPY PACK

Catalog Number	DYNJ23137J
Medical Device Problem Code	Material Integrity Problem (2978)
Health Effect - Clinical Code	Foreign Body In Patient (2687)
Date of Event	10/17/2023
Type of Reportable Event	Serious Injury
Event or Problem Description
According to the facility on 10/17/2023 during a knee arthroscopy the #11 blade broke in half.Per the facility "half stayed with the handle and half in the knee".
Additional Manufacturer Narrative
According to the facility on (b)(6) 2023 during a knee arthroscopy the #11 blade broke in half.Per the facility "half stayed with the handle and half in the knee".Per the facility the blade was retrieved, and all pieces were accounted for.Per the facility the patient is "fine", and no serious injury was noted.No additional information is available at this time.The sample was requested for evaluation.It has been determined that the reported event could cause or contribute to serious injury if it were to occur.In an abundance of caution, this medwatch is being filed.If any further relevant information is identified or obtained, a supplemental medwatch will be submitted.

• Common Device Name: KNEE ARTHROSCOPY PACK
• Manufacturer (Section D): MEDLINE INDUSTRIES, LP; three lakes drive; northfield IL 60093
• Manufacturer Contact: justin herrmann ; three lakes drive; northfield, IL 60093
• MDR Report Key: 18105533
• Report Number: 1423395-2023-00070
• Device Sequence Number: 6004255
• Product Code: OJH
• UDI-Device Identifier: 10889942716814
• UDI-Public: 10889942716814
• Combination Product (Y/N): N
• Initial Reporter State: MN
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Health Professional
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 11/09/2023

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Operator of Device: Health Professional
• Device Catalogue Number: DYNJ23137J
• Device Lot Number: 23HMH376
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 10/26/2023
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 10/17/2023
• Initial Report FDA Received Date: 11/09/2023
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): Yes
• Usage of Device: Unknown
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Other
• Patient Sex: Unknown