MAUDE Adverse Event Report: SMITH & NEPHEW, INC. SMART TSF WIRE COMBI BOLT; WASHER, BOLT, NUT, NON-SPINAL, METALLIC

Catalog Number 71075284

Device Problems Fracture (1260); Mechanical Jam (2983)

Patient Problem No Clinical Signs, Symptoms or Conditions (4582)

Event Date 02/12/2024

Event Type  malfunction  

Manufacturer Narrative

H10: internal complaint reference (b)(4).

Event Description

It was reported that, during tsf removal, nine (9) smart tsf wire fixation bolts snapped into two parts while the surgeon was trying to move wires on the footplate.It seems the 10mm nuts and the bolts are fused somehow.Some of the nuts broke and were discarded.Removal surgery was completed after a delay greater than 30 min.

Manufacturer Narrative

The associated devices were returned and evaluated.The visual inspection revealed only one bolt long is broke into two pieces.Both pieces were returned.These devices show signs of extensive wear and use.This inspection was conducted by naked eye.A functional evaluation performed on the devices revealed the nuts seized on the bolts and cannot be removed.Devices batch numbers were not provided, thus, an evaluation of the manufacturing records could not be performed.For the bolt, a review of complaint history of the previous 12 months revealed similar events for the listed device, this failure mode will be monitored for future complaints for any necessary corrective actions.For the bolt long and the nut, a review of complaint history for the part number over the past 12 months and for the batch number based on historical data of the device did not reveal similar events for the listed device.A review of the surgical technique for smart tsf revealed that it is the responsibility of treating physicians to determine and utilize the appropriate products and techniques, according to their own clinical judgment, for each of their patients.A review of the risk management files 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 these products and event.For the bolt, according with material specification, the quality and manufacture for stainless steel shall be controlled.For the nut, according with the drawing print the sharp edges should be broken.At this time, we have no evidence to conclude that the products failed to meet any specifications at the time of manufacture.Factors that could contribute to the reported event include user error, excessive forces and/or procedural technique.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.

Event Description

It was reported that, during tsf removal, nine (9) smart tsf wire fixation bolts snapped into two parts while the surgeon was trying to move wires on the footplate.It seems the 10mm nuts and the bolts are fused somehow.Since the combi bolt and nuts wouldn¿t come apart, they had to break the bolt in order to move forward with the procedure.Removal surgery was completed after a delay greater than 30 min.

• Brand Name: SMART TSF WIRE COMBI BOLT
• Type of Device: WASHER, BOLT, NUT, NON-SPINAL, METALLIC
• 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: 18855966
• MDR Text Key: 337103680
• Report Number: 1020279-2024-00506
• Device Sequence Number: 1
• Product Code: NDG
• UDI-Device Identifier: 00885556746028
• UDI-Public: 885556746028
• Combination Product (y/n): N
• Reporter Country Code: US
• 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,Followup
• Report Date: 04/18/2024

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 03/07/2024
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Catalogue Number: 71075284
• Device Lot Number: UNKNOWN
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 03/04/2024
• Is the Reporter a Health Professional?: Yes
• Date Manufacturer Received: 04/12/2024
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1
• Treatment: MALE HINGE (PN:101600,LN:22FP02221); MALE SPPRT 2HLS(PN:101400,LN:22LP03949); MALE SPPRT 3HLS(PN:101401,LN:22FP02182); NUT 10MM (PN:103300); SMRT TSF WR CMB BLT LNG (PN:71075283)