Method: visual inspection; functional inspection; device history review; complaint history review; risk assessment.Results: the reported disengagement was confirmed through inspection of the device.The inspection revealed deformation on the screw tulip around the edge of the bone screw hole, which suggests that the issue occurred during persuasion as there was no deformation on the bone screw head.Conclusion: however, multiple factors can also affect this, including surgeon technique and the condition of the existing construct.Due to the multifactorial nature of the event, the root cause cannot be determined conclusively.
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