MAUDE Adverse Event Report: DEPUY IRELAND - 9616671 ATTUNE IM ROD; ATTUNE INSTRUMENTS : ALIGNMENT DEVICES

Catalog Number 254400502

Device Problem Material Integrity Problem (2978)

Patient Problem Insufficient Information (4580)

Event Date 09/25/2023

Event Type  malfunction  

Manufacturer Narrative

Product complaint # (b)(4).Investigation summary: it was reported that once the distal femoral resection guide was placed into the femoral canal and the cutting block was pinned, surgeon went to remove the intramedulary rod and it became lodged in the canal.He ended up needing to use a pair of vice grips to remove the rod and damaged the connection point between the rod and the handle.No parts were broken off, the case was delayed approximately 10 minuets but there was no harm to the patient and all parts of the instrument were removed from the surgical field immediately.I have no further information regarding this situation.The device associated with this report was returned to depuy synthes for evaluation.Visual analysis of the returned sample revealed that attune im rod was found broken from the handle, fragments were not received.Therefore the alleged reported condition was confirmed.No other issue was identified a dimensional inspection for the attune im rod was not performed due to post manufacturing damage.The observed condition of the device was consistent with a random component failure that may have been caused by exposure to unintended forces.The overall complaint was confirmed as the observed condition of the attune im rod would contribute to the complained device issue.Based on the investigation findings, the potential cause is traced to unintended use error.There is no indication that a design or manufacturing issue has caused the reported complaint condition.As part of depuy synthes quality process, all devices are manufactured, inspected, and released to approved specifications.Additional monitoring for any potential safety signals will be conducted through complaint trending and other post-market safety surveillance activities.Device history lot: the product investigation found no evidence suspecting an error in the manufacturing or material that would be a contributing factor in the reported allegation(s).A manufacturing records evaluation (mre) was not performed.This report is being submitted pursuant to the provisions of 21 cfr, part 803 (and/or part 4, as applicable).This report may be based on information which has not been investigated or verified prior to the required reporting date.This report does not reflect a conclusion by depuy synthes, or its employees that the report constitutes an admission that the product, depuy synthes, or its employees caused or contributed to the potential event described in this report.If information is obtained that was not available for the initial report, a follow-up report will be filed as appropriate.

Event Description

It was reported that distal femoral resection guide was placed into the femoral canal and the cutting block was pinned, surgeon went to remove the intramedullary rod and it became lodged in the canal.No parts were broken off, the case was delayed approximately 10 mins but there was no harm to the patient and all parts of the instrument were removed from the surgical field immediately.

• Brand Name: ATTUNE IM ROD
• Type of Device: ATTUNE INSTRUMENTS : ALIGNMENT DEVICES
• Manufacturer (Section D): DEPUY IRELAND - 9616671; loughbeg ringaskiddy co.; cork ; EI
• Manufacturer (Section G): DEPUY ORTHOPAEDICS, INC. 1818910; 700 orthopaedic dr.; warsaw IN 46581 0988
• Manufacturer Contact: kate karberg ; 700 orthpaedic dr.; warsaw, IN 46581 ; 3035526892
• MDR Report Key: 18131564
• MDR Text Key: 328055100
• Report Number: 1818910-2023-23156
• Device Sequence Number: 1
• Product Code: HWT
• UDI-Device Identifier: 10603295130024
• UDI-Public: 10603295130024
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: EXEMPT
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Health Professional,Company Representative
• Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date: 11/14/2023

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 11/14/2023
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Catalogue Number: 254400502
• Device Lot Number: AB5131870
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 11/07/2023
• Is the Reporter a Health Professional?: Yes
• Date Manufacturer Received: 11/08/2023
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 04/14/2021
• Is the Device Single Use?: No
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Unknown
• Patient Sequence Number: 1