It was reported that, during an internal fixation surgery, a drill bit snapped and is now stuck in an evos 2.5mm snap in serrated drill guide.It broke while drilling in the patient but the piece that broke is lodged in the tissue protector.Nothing had to be retrieved from the patient.The procedure was resumed, without any delay, using a s+n back-up device.No injury was reported as a consequence of this issue.
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H3, h6: the device was not returned for evaluation; therefore, a device analysis could not be performed.For the evos plating drill device specific identifiers were not provided.Therefore, an evaluation of the manufacturing records, complaint history review, risk management file and prior actions review could not be performed.For the snap in serrated drill guide a review of the production order did not reveal a manufacturing abnormality that could have caused or contributed to the reported incident.A review of complaint history revealed a similar event for the listed device over the previous 12 months, but no similar events for the batch based on the historical data, this failure mode will be monitored for future complaints for any necessary corrective actions.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 evidence to conclude that the product failed to meet any specifications at the time of manufacture.This device is a reusable instrument that can be exposed to numerous surgeries.Damage from prolonged use, misuse or rough handling are likely potential factors that could contribute to the reported event.We recommend that all reusable instruments be routinely inspected for wear and damage and replaced as necessary.Based on this investigation, the need for corrective action is not indicated.Should the device or 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.
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