MAUDE Adverse Event Report: ARTHREX, INC. DBL LOADED 4.75MM PEEK SWVLK; BIO SOFT TISSUE FIXATN FASTNR

Model Number	DBL LOADED 4.75MM PEEK SWVLK
Medical Device Problem Code	Material Split, Cut or Torn (4008)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	07/19/2021
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.The complaint allegation cannot be confirmed without the device for evaluation.According to the event description, the most likely cause of this condition is a sharp bone that damaged the suture while pulling against it.
Event or Problem Description
It was reported during a rotator cuff repair procedure, the surgeon inserted and seated the ar-2324pslc-2 double loaded peek swivelock, (lot: 12900335) as the surgeon was tightening down on the white suture, he notice the suture was cut from the eyelet.The broken suture was removed from the patient.The blue suture was use to secure the ar-2324pslc-2.The surgeon used a second ar-2324pslc-2 (lot: 13262585) and the same issue occurred.The case was completed without patient harm.

• Brand Name: DBL LOADED 4.75MM PEEK SWVLK
• Common Device Name: BIO SOFT TISSUE FIXATN FASTNR
• 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: 19570117
• Report Number: 1220246-2024-06203
• Device Sequence Number: 15197050
• Product Code: MAI
• UDI-Device Identifier: 00888867251243
• UDI-Public: 00888867251243
• Combination Product (Y/N): N
• Initial Reporter State: TX
• Initial Reporter Country: US
• PMA/510(K) Number: K101823
• 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): 06/19/2024

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 Expiration Date: 04/30/2026
• Device Model Number: DBL LOADED 4.75MM PEEK SWVLK
• Device Catalogue Number: AR-2324PSLC-2
• Device Lot Number: 13262585
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 07/19/2021
• Initial Report FDA Received Date: 06/19/2024
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 05/06/2021
• 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