MAUDE Adverse Event Report: SMITH & NEPHEW, INC. GII PRIM P/S COLLET W/THMBSCRW; PRSTHSIS,KNEE,PATELLO/FEMROTIBIL,UNCMNTD,POROUS,COATD,PLYMR/MTL/POLYMER

Model Number	71440467
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	11/19/2019
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that during surgery the surgeon broke off the gold knob of the instrument with a mallet on accident inside the patient.All pieces were retrieved from the patient.The procedure was successfully completed with the same device.
Additional Manufacturer Narrative
The device, used in treatment, was returned for evaluation.A visual inspection of the returned collet confirms the washers are missing.The collet, captured screw and thumbnut were returned for evaluation.The device shows excessive signs of wear/usage.The device was manufactured in 2011.A review of complaint history on the listed part revealed no prior complaint for the listed batch with the same failure mode.A review of the manufacturing records did not reveal a manufacturing abnormality that could have caused or contributed to the reported incident.This device is a reusable instrument that can be exposed to numerous surgeries; damage from repeated use can occur.Expected wear/tear is likely the probable cause of the reported event.We recommend that all reusable instruments be routinely inspected for wear and damage and replaced as necessary.At this time, we have no reason to suspect that the product failed to meet any product specifications at the time of manufacture.Based on this investigation, the need for corrective action is not indicated.Should additional information be received, the complaints will be reopened.No further investigation is warranted for these complaints; however we will continue to monitor for future complaints and investigate as necessary.

• Brand Name: GII PRIM P/S COLLET W/THMBSCRW
• Common Device Name: PRSTHSIS,KNEE,PATELLO/FEMROTIBIL,UNCMNTD,POROUS,COATD,PLYMR/MTL/POLYMER
• Manufacturer (Section D): SMITH & NEPHEW, INC.; 1450 brooks road; memphis TN 38116
• MDR Report Key: 9471065
• Report Number: 1020279-2019-04400
• Device Sequence Number: 458614
• Product Code: MBH
• UDI-Device Identifier: 03596010443076
• UDI-Public: 03596010443076
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K121393
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 02/18/2020

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: 71440467
• Device Catalogue Number: 71440467
• Device Lot Number: 11HM06232
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 12/05/2019
• Initial Date Received by Manufacturer: 11/19/2019
• Supplement Date Received by Manufacturer: 02/12/2020
• Initial Report FDA Received Date: 12/15/2019
• Supplement Report FDA Received Date: 02/18/2020
• Patient Sequence Number: 1