MAUDE Adverse Event Report: SMITH & NEPHEW, INC. TWINFIX ULTRA PK 4.5MM W/2 UB -WHT &BL; FASTENER, FIXATION, NONDEGRADABLE, SOFT TISSUE

Model Number 72202595

Device Problem Material Separation (1562)

Patient Problem No Information (3190)

Event Date 09/28/2020

Event Type  Injury  

Event Description

It was reported that, during a patellar avulsion fracture surgery, after drilling a hole by appropriative tap, the "twinfix anchor (ultra pk 4.5mm)" was fractured when screwed-in for 1/4.Although the surgery was not significantly delayed, it is unknown if a back-up device was available to complete the procedure.No further complications were reported.All available information has been disclosed.If additional information should become available, a supplemental report will be submitted accordingly.

Event Description

It was reported that, during a patellar avulsion fracture surgery, after drilling the hole by appropriative tap, the "twinfix anchor (ultra pk 4.5mm)" was fractured in the threads when screwed-in for 1/4.All the pieces were successfully removed from the patient using tweezers.The procedure was successfully completed without significant delay using a back-up device into the same bone hole.No additional complications were reported.

Manufacturer Narrative

H10 h3, h6 the reported device, used in treatment, was received for evaluation.There was a relationship found between the returned device and the reported incident.A review of customer provided images showed a cracked screw on the end of the inserter.A visual inspection revealed that device was returned with screw attached to inserter.Screw was cracked and deformed, but not fractured.Based on the condition of the product material found during visual inspection it was determined that additional material testing is not required.A review of the device records showed there were no indications to suggest that the product did not meet manufacturing specification or would not be able to perform as intended.A complaint history review concluded this was an isolated event.A review of risk management files found that the reported failure was documented appropriately.The instructions for use were reviewed and found to include conditions of off label use and technique specifics, as well as precautions and warnings related to the use of the device.A review of the material found that the storage protocols, material specifications, and material tests were appropriately documented.A material certificate of analysis was required for the raw material.The complaint was confirmed.Factors that could have contributed to the reported event include off-axis insertion, excessive force or excessive torque, or improper preparation of the insertion site.

• Brand Name: TWINFIX ULTRA PK 4.5MM W/2 UB -WHT &BL
• Type of Device: FASTENER, FIXATION, NONDEGRADABLE, SOFT TISSUE
• Manufacturer (Section D): SMITH & NEPHEW, INC.; 130 forbes blvd.; mansfield MA 02048
• MDR Report Key: 10687212
• MDR Text Key: 211630544
• Report Number: 1219602-2020-01587
• Device Sequence Number: 1
• Product Code: MBI
• UDI-Device Identifier: 03596010647467
• UDI-Public: 03596010647467
• Combination Product (y/n): N
• PMA/PMN Number: K093228
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative,foreig
• Type of Report: Initial,Followup,Followup
• Report Date: 06/08/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 10/15/2020
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: 72202595
• Device Catalogue Number: 72202595
• Device Lot Number: 2041180
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 11/09/2020
• Date Manufacturer Received: 06/04/2021
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1
• Patient Outcome(s): Required Intervention
• Patient Age: 29 YR
• Patient Weight: 75