Roi-a : the inserter became detached from the cage during impaction of anchoring plate.During surgery, while surgeon impacting the first anchoring plate in the cage, the cage and the implant holder detached from each other.The reporter do not know if this was due to the force used for the impaction of the anchoring plate.Patient has hard bones.Cage and anchoring plates were removed.The surgery was completed with new cage and new anchoring plate.During this second implantation, the starter awl was used before insertion of the anchoring plate.Additional information received on oct.12th 2018 by email : the patient is fine.The cage was loaded properly.The tightening was done by hand.The axis and angulations were correct during insertion.Proper steps followed for the impactors.The first anchoring plate never was fully seated as it broke along with the cage.
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This medwatch is intended to provide additional information received upon the device examination and to correct the conclusion sent in the previous report the products were received on (b)(6) 2019 , therfore examintaion was performed on the returned product.The reported event is confirmed: the roi-a cage reference ir5345p and lot 910117000r10 is damaged.Considering the fissures starting point, excessive stresses were applied on the roi-a cage thread during the locking of the implant on the implant holder, causing its fracture during the setting-up.From the information provided based on the complaint report description , the product history records, the review of the case with the project manager, the recurrence of this type of event for this product and after having performed the product evaluation, the investigation found no evidence to indicate a device related issue.Indeed, excessive stresses were applied on the cage roi-a thread during the locking of the implant on the implant holder, causing the implant fracture during the setting-up.It is clearly stated in the surgical technique to make sure the cage is perfectly stable and properly fixed on the cage holder (step 6: cage preparation).Root cause : mishandling during cage -inserter assembly.
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