MAUDE Adverse Event Report: SMITH & NEPHEW, INC. MIS 3.2MM X 30MM RIMMED PIN STERILE; PROSTHESIS, KNEE, FEMOROTIBIAL, NON-CONSTRAINED, CEMENTED, METAL/POLYMER

Catalog Number 74016464

Device Problem Improper or Incorrect Procedure or Method (2017)

Patient Problems Foreign Body In Patient (2687); Device Embedded In Tissue or Plaque (3165)

Event Date 09/14/2023

Event Type  Injury  

Event Description

It was reported that during tka surgery, while attempting to pin down the trial tibia baseplate the mis 3.2mm x 30mm rimmed pin sterile was dropped into the intramedullary hole that was previously drilled by the surgeon.Multiple attempts were made to remove the rimmed speed pin from the patients tibia, but the surgeon decided to leave the piece inside of the patient and proceed to implant the final pressfit tibia plate.The procedure was completed after a non significant delay using a s+n back up device.

Manufacturer Narrative

Internal complaint reference: (b)(4).

Manufacturer Narrative

H3, h6: the device was not returned for evaluation; therefore, a device analysis could not be performed.The clinical/medical investigation concluded that human error was the contributing factor to the reported event.The patient impact includes the 0-30 minute surgical extension, the reported multiple attempts made to remove the foreign body, the retained/embedded foreign body within the intramedullary canal and use of a back-up device to complete the procedure.The foreign body/speed pin is reportedly inside the tibial intramedullary canal and although unlikely, possible micro-motion and/or migration, and local irritation/discomfort cannot be definitively ruled out.Additional patient impact cannot be determined.Although the speed pin is manufactured and intended as an externally communicating device, it is composed of stainless-steel type 431 which is approved for some medical implant applications.No further medical assessment can be rendered at this time.Device batch number was not provided, thus, an evaluation of the manufacturing records could not be performed.A review of complaint history for the previous 12 months did not reveal similar events for the listed device.A review of the instructions for use documents for knee systems revealed that rimmed speed pins are not intended for implantation.This has been identified as a contraindication.A review of the risk management file revealed this failure mode was previously identified.The anticipated risk level is still adequate.A historical review concluded that there are no prior actions related to this product and event.At this time, we have no reason to suspect that the product failed to meet any specifications at the time of manufacture.A factor that could contribute to the reported event include user/procedural variance.Based on this investigation, the need for corrective action is not indicated.Should additional information be received, the complaint will be reopened.No further investigation is warranted for this complaint; however, we will continue to monitor for future complaints and investigate as necessary.We consider this investigation closed.

• Brand Name: MIS 3.2MM X 30MM RIMMED PIN STERILE
• Type of Device: PROSTHESIS, KNEE, FEMOROTIBIAL, NON-CONSTRAINED, CEMENTED, METAL/POLYMER
• Manufacturer (Section D): SMITH & NEPHEW, INC.; 1450 brooks rd.; memphis TN 38116
• Manufacturer (Section G): SMITH & NEPHEW, INC.; 1450 brooks rd.; memphis TN 38116
• Manufacturer Contact: holly topping ; 7000 west william cannon drive; austin, TX 78735 ; 5123913905
• MDR Report Key: 17890927
• MDR Text Key: 325228501
• Report Number: 1020279-2023-01898
• Device Sequence Number: 1
• Product Code: HSX
• UDI-Device Identifier: 00885556691977
• UDI-Public: 885556691977
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K113038
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Health Professional,Company Representative
• Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date: 11/03/2023

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 10/06/2023
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Operator: Health Professional
• Device Catalogue Number: 74016464
• Device Lot Number: UNKNOWN
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Date Manufacturer Received: 11/02/2023
• Was Device Evaluated by Manufacturer?: No
• Is the Device Single Use?: No
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1
• Patient Outcome(s): Other
• Patient Age: 72 YR
• Patient Sex: Male
• Patient Weight: 138 KG