TORNIER INC AEQUALIS FLEX REVIVE TRIAL SPACER 9DIA 20MM; PROSTHESIS, SHOULDER, HEMI-, HUMERAL, METALLIC UNCEMENTED
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Catalog Number ARS742401 |
Device Problems
Break (1069); Corroded (1131); Fracture (1260); Material Deformation (2976); Naturally Worn (2988)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 11/02/2023 |
Event Type
Injury
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Manufacturer Narrative
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Analysis results are not available at the time of this report.A follow-up report will be sent when the analysis is complete.
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Event Description
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During a recent surgery for a total reverse fracture case, a portion of the 9x20 trial spacer from the tornier flex revive humeral instruments tray fractured and became stuck inside the humeral canal.This incident caused a significant delay in the surgery.The surgical team had to remove a section of the humerus to access and remove the trapped trial stem, which was later reattached using cerclage.The incident resulted in a 3-hour surgical delay, but all debris was successfully removed using a bur instrument.
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Manufacturer Narrative
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The reported event was confirmed, since the product was returned for evaluation and matches the alleged failure mode.The device inspection revealed the following: the received device shows signs of extensive usage as evident by scratches, gouges, presence of water marks and heavy corrosion marks.The device has deformation and breakage around the centre pin and at the pegs resulting from an improper handling, frequent usage and application of excessive mechanical force.A review of the device history for the reported lot did not indicate any abnormalities.No corrective actions are required at this time.No indications of material, manufacturing or design related problems were found during the investigation.A review of the labeling did not indicate any abnormalities.Based on investigation, the root cause was attributed to a combination of wear and user related issue.The failure was caused by an improper handling, extensive usage and application of excessive mechanical force.If any further information is provided, the complaint report will be updated.
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Event Description
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During a recent surgery for a total reverse fracture case, a portion of the 9x20 trial spacer from the tornier flex revive humeral instruments tray fractured and became stuck inside the humeral canal.This incident caused a significant delay in the surgery.The surgical team had to remove a section of the humerus to access and remove the trapped trial stem, which was later reattached using cerclage.The incident resulted in a 3-hour surgical delay, but all debris was successfully removed using a bur instrument.
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Search Alerts/Recalls
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