MAUDE Adverse Event Report: ARTHREX, INC. 4K ARTHROSCOPE, 30°, 4 MM X 152.5 MM; ARTHROSCOPE AND ACCESSORIES

Model Number	4K ARTHROSCOPE, 30°, 4 MM X 152.5 MM
Medical Device Problem Code	Detachment of Device or Device Component (2907)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	11/06/2023
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 11/6/2023, it was reported by a facility representative via sems-06392638 that an ar-3350-4031 arthroscope came apart during surgery.The eyepiece detached itself from the scope.This was discovered during the case with no patient harm.
Additional Manufacturer Narrative
Additional information: complaint is not confirmed.Upon visual evaluation, it was noted that the lens was cracked and around the metal part had nicks.No parts were detached from the device.No problem found.

• Brand Name: 4K ARTHROSCOPE, 30°, 4 MM X 152.5 MM
• Common Device Name: ARTHROSCOPE AND ACCESSORIES
• 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: emily shafer ; 8009337001
• MDR Report Key: 18209574
• Report Number: 1220246-2023-08917
• Device Sequence Number: 17985389
• Product Code: HRX
• UDI-Device Identifier: 00888867291690
• UDI-Public: 00888867291690
• Combination Product (Y/N): N
• Initial Reporter State: MN
• Initial Reporter Country: US
• PMA/510(K) Number: K080560
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: User Facility
• Initial Reporter Occupation: Administrator/Supervisor
• Type of Report: Initial,Followup
• Report Date (Section B): 11/20/2024

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 Model Number: 4K ARTHROSCOPE, 30°, 4 MM X 152.5 MM
• Device Catalogue Number: AR-3350-4031
• Device Lot Number: 15026757
• Was Device Available for Evaluation?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 11/06/2023
• Supplement Date Received by Manufacturer: 01/15/2024
• Initial Report FDA Received Date: 11/27/2023
• Supplement Report FDA Received Date: 11/20/2024
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Is the Device Labeled for Single Use? (Y/N): No
• 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