MAUDE Adverse Event Report: ARTHREX, INC. INSTRUMENT CASE, UNIVERS VAULTLOCK GLEN; MANUAL INSTR, GENERAL SURGICAL

Model Number	INSTRUMENT CASE, UNIVERS VAULTLOCK GLEN
Medical Device Problem Code	Corroded (1131)
Health Effect - Clinical Code	Insufficient Information (4580)
Date of Event	03/12/2021
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
This 3500a record is submitted to comply with an fda 483 inspectional observation issued to arthrex inc on may 5, 2023.Arthrex has reassessed the reportability decisions made on historical complaint records using revised criterion.This 3500a document is a result of the reassessment.Complaint confirmed.Visual inspection identified corrosion spots inside both caddies.The most likely causes of the event is repeated use and cleaning cycles, improper cleaning.
Event or Problem Description
It was reported by the agency that the following devices are corroded: ar-9231-01pp qty 1 ar-9231-02pp qty 1 ar-9231-03pp qty 1 ar-9231-04pp qty 1 ar-9217cpp qty 2 ar-9225ck qty 1 ar-9225cp qty 1.

• Brand Name: INSTRUMENT CASE, UNIVERS VAULTLOCK GLEN
• Common Device Name: MANUAL INSTR, GENERAL SURGICAL
• 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: jared engle ; 8009337001
• MDR Report Key: 19222610
• Report Number: 1220246-2024-02684
• Device Sequence Number: 8194759
• Product Code: MDM
• UDI-Device Identifier: 00888867249752
• UDI-Public: 00888867249752
• Combination Product (Y/N): N
• Initial Reporter State: FL
• Initial Reporter Country: US
• PMA/510(K) Number: EXEMPT
• 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): 05/01/2024

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: INSTRUMENT CASE, UNIVERS VAULTLOCK GLEN
• Device Catalogue Number: AR-9217C
• Device Lot Number: 51098
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 06/14/2021
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 03/12/2021
• Initial Report FDA Received Date: 05/01/2024
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 07/11/2016
• 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: Reuse
• Patient Sequence Number: 1
• Patient Sex: Unknown