It was reported that, during a bhr surgery, the introducer wire of an acetabular cup hap size 52/58 snapped during impaction.The procedure was performed, after a non-significant delay, with a s+n back-up device.Patient was not injured as consequence of this problem.
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Additional information: h6 (component code, type of investigation, investigation findings, investigation conclusions).Results of investigation: it was reported that, during a bhr surgery, the introducer wire of an bhr acetabular cup snapped during impaction.The procedure was performed, after a non-significant delay, with a s+n back-up device.Patient was not injured as consequence of this problem.The device, for use in treatment, has not been returned for evaluation.A review of the historical complaints data for the devices concerned was performed.No other complaints were identified involving this batch.No similar complaints have been received in the past 12 months for the bhr cup.In the absence of the returned device, the inspection procedure for the applicable batch of cup wire reels was reviewed.All product was verified to meet the required standards, with no issues noted.The alleged failure modes and associated risks have been anticipated within the risk file and the anticipated risk level is still adequate.Any identified risks are reduced in severity, occurrence and detection as far as possible.A review of prior escalation actions and the the device labelling confirmed that the following statement was added to the bhr surgical technique in 2010: "cautionary statement do not over tighten the acetabular component on the introducer.Over tightening and excessive wire tension may cause wire breakage." no further escalation actions are required based on this complaint.It should be noted as per the surgical technique that when attaching the cup using the wires and cup introducer, tension should be applied until the cup is securely attached to the introducer assembly.Care should be taken with over tightening and excessive wire tension as this may lead to wire breakage.After investigation, the potential root cause is user error, it cannot be concluded that the functional complications were associated with a mal-performance of the implant.No preventative or corrective action has been initiated as a result of this investigation.
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