It was reported that, during a thr surgery, the internal wire tensioner of a bhr curved cup introducer broke off upon impaction of the acetabular cup.No surgical delay was reported to occur due to this incident, and the procedure was concluded with a smith and nephew back up device.No patient harm was reported to occur as a consequence of this malfunction.
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H3, h6: it was reported that, during a thr surgery, the internal wire tensioner of a bhr curved cup introducer (part number: 90128257, lot number: s0801109) broke off upon impaction.No surgical delay was reported, and the procedure was concluded with a smith and nephew back up device.Both pieces remained connected to the impactor and were accounted for.No patient harm was reported.The instrument is for use in treatment.A review of the complaint history for the bhr curved cup introducer was performed using batch numbers in search of similar recurring reports for the products during their lifetimes.Similar complaints have been identified.This will continue to be monitored.As the supplier is no longer in business and there is no traceability within sap addition to the age of the instrument (>10 years old), the manufacturing records for the instrument cannot be reviewed.However, the released instrument involved would have met manufacturing specifications at the time of production.A risk management review was performed.No additional risks were identified as result of the reported event.The alleged failure modes and associated risks have been anticipated within the risk file and the anticipated risk level is still adequate.It should be noted that the bhr surgical technique (us) states, "examine instruments for wear or damage before use.While rare, intra-operative instrument breakage can occur.Instruments that have experienced excessive use or force may be susceptible to breakage¿.Without return of the actual devices or further information we cannot further investigate or confirm the reported complaint.If the products or additional information become available in the future, this case will be reopened.Without additional information about this particular case, our investigation remains inconclusive.Based on the results of this investigation, the need for corrective or preventative action is not indicated.
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