SMITH & NEPHEW ORTHOPAEDICS LTD OFFSET CUP INTRODUCER; PROSTHESIS, HIP, SEMI-CONSTRAINED, METAL/METAL, RESURFACING
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Catalog Number 90128275 |
Device Problem
Fracture (1260)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 10/10/2023 |
Event Type
malfunction
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Manufacturer Narrative
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Internal complaint reference (b)(4).
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Event Description
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It was reported that, during a thr, the threaded rod in one (1) offset cup introducer broke during impaction of the bhr shell.No pieces were noticed by the surgeon in the wound.The procedure was resumed, without any delay, using a s+n back-up device.Patient was not harmed as consequence of this problem.
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Manufacturer Narrative
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An offset cup introducer, for use in treatment, was returned for evaluation.It was reported that the threaded rod broke during impaction of bhr shell.The procedure was resumed, without any delay, using a smith+nephew back-up device.A visual inspection of the returned device reveals several components from the chain assembly broke off.These pieces were not returned.Functional evaluation not performed as failure confirmed through visual inspection.A review of the historical complaints data for the devices concerned was performed using batch numbers, part numbers and the reported failure modes to evaluate patterns of repeated failures or defects.Similar complaints have been identified.This will continue to be monitored via routine trending.The production records were reviewed for the devices reportedly involved in this incident.All the released devices involved met manufacturing specifications at the time of production.A risk management review was performed.No additional risks were identified as result of the reported event.The alleged failure modes and associated risks have been anticipated within the risk file and the anticipated risk level is still adequate.A review of historic quality escalations was performed.Following the review, no prior applicable escalation actions were identified.Based on the information provided our investigation remains inconclusive and a definitive root cause cannot be determined.Factors known to contribute to the alleged fault include excessive use or force, making the instrument susceptible to breakage.It should be noted that the bhr surgical technique states ¿examine instruments for wear or damage before use.While rare, intra-operative instrument breakage can occur.Instruments that have experienced excessive use or force may be susceptible to breakage.¿ the device will be retained.Based on this investigation the need for corrective and preventative action is not indicated.
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