MAUDE Adverse Event Report: BLUE BELT TECHNOLOGIES NAVIO TKA PLANE VISUALIZATION TOOL; ORTHOPEDIC STEREOTAXIC INSTRUMENT

Model Number	ROB00004
Medical Device Problem Code	Connection Problem (2900)
Health Effect - Clinical Code	No Patient Involvement (2645)
Date of Event	07/31/2019
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that a plate probe had a fit issue, it could not be locked into the collet and was tight when removing it.No patient involved.
Additional Manufacturer Narrative
Memo for the submission added - attachment: [memo - mdr submissions.Pdf].
Additional Manufacturer Narrative
Section d10 was corrected.Section h10: the device was being used during treatment and was not returned for evaluation.Thus, visual inspection was not performed.The dhr was reviewed for pn (b)(6) /lot c1306912 and found a lot that was related to fit issues between the handpiece and visualization tool.A complaint history review was performed and found similar reports of the issue.This issue will continue to be monitored.A relationship between the device and the reported event has been established.This lot of the plate probe was found to have an incorrect notch curvature.Therefore, this issue prevented the plate probe from fully locking in and it was not machined with sufficient space to allow proper locking with the handpiece.The reported event can be confirmed.Therefore, the root cause of the reported event was due to supplier/raw material fault.There has been a corrective action opened to address this issue and it is being further investigated.

• Brand Name: NAVIO TKA PLANE VISUALIZATION TOOL
• Common Device Name: ORTHOPEDIC STEREOTAXIC INSTRUMENT
• Manufacturer (Section D): BLUE BELT TECHNOLOGIES; 2905 northwest blvd ste 40; plymouth MN 55441
• MDR Report Key: 9999762
• Report Number: 3010266064-2020-01518
• Device Sequence Number: 2078563
• Product Code: OLO
• UDI-Device Identifier: 00885556685068
• UDI-Public: 00885556685068
• Combination Product (Y/N): N
• Initial Reporter Country: IT
• PMA/510(K) Number: K191223
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 08/28/2020

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: ROB00004
• Device Catalogue Number: ROB00004
• Device Lot Number: 1306912
• Was Device Available for Evaluation?: No
• Date Returned to Manufacturer: 08/29/2019
• Initial Date Received by Manufacturer: 07/31/2019
• Supplement Date Received by Manufacturer: 07/31/2019; 08/26/2020
• Initial Report FDA Received Date: 04/27/2020
• Supplement Report FDA Received Date: 04/27/2020; 08/28/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1