MAUDE Adverse Event Report: BIOMET MICROFIXATION 90° CONTRA ANGLE DRIVER; PLATE, BONE

Model Number N/A

Device Problem Device Contamination with Body Fluid (2317)

Patient Problem No Patient Involvement (2645)

Event Date 09/30/2019

Event Type  malfunction  

Manufacturer Narrative

Zimmer biomet complaint (b)(4).Lot numbers determined upon product receipt, and additional mdr reports are being submitted for each lot number received.Multiple mdr reports were filed for this event, please see associated reports: 0001032347-2019-00480, 0001032347-2020-00042, 0001032347-2020-00043, 0001032347-2020-00044.Medical products: 90° contra angle driver, part# 24-1189, lot# 474720.90° contra angle driver, part# 24-1189, lot# 129290.90° contra angle driver, part# 24-1189, lot# 449720.90° contra angle driver, part# 24-1189, lot# 003000.The user facility is foreign; therefore a facility medwatch report will not be available.Report source ¿ (b)(6).The complaint was opened because (b)(6), sales rep reports a screwdrivers with deposits of tissue and blood post sterilization.The four (4) 90 deg contra angle screwdrivr (part# 24-1189, lot# 474720, 129290, 449720, 003000) were returned for investigation.It was reported that the sterilization department opened the head of the screwdrivers (after cleaning and sterilization).According to the employee there were deposits of tissue and blood present.Protein test was performed and the test result was positive.Because the instruments were tested by the hospital with positive protein results, the complaint is considered confirmed.Visual evaluation showed all four of the contra angle drivers appeared to be in good overall condition.The drivers were disassembled for further inspection.The three drivers with lot numbers 474720, 129290, and 449720 were easily disassembled and were fairly clean internally, which would be consistent with the report that the drivers were cleaned, disassembled, and tested for protein.The fourth driver with lot number 003000 was returned with a contra angle blade (sp-2379) stuck inside the head assembly.This driver was difficult to disassemble and had lots of debris inside the head assembly.Following the report that protein was detected in the head assemblies of these drivers, validation #2019-57 - contra angle (24-1189) end user cleaning validation (includes us & ous parameters) was conducted.This cleaning validation proved that following the ifu's cleaning instructions eliminated all possibility of residual proteins within the instrument.The dhr's for these products were reviewed, no non-conformances were found.There are no indications of manufacturing defects.This is the only complaint regarding deposits of tissue and blood for this part# 24-1189, lot #'s 474720, 129290, 449720, and 003000.Therefore, the most likely underlying cause of the complaint is that the user did not follow the cleaning instructions detailed in the ifu.If any further information is found which would change or alter any conclusions or information, a supplemental report will be filed accordingly.Zimmer biomet will continue to monitor for trends.

Event Description

It was reported an instrument contained blood and tissue following the cleaning and sterilization process.Protein test was performed and the test result was positive.No adverse events were reported as a result of this malfunction.

• Brand Name: 90° CONTRA ANGLE DRIVER
• Type of Device: PLATE, BONE
• Manufacturer (Section D): BIOMET MICROFIXATION; 1520 tradeport drive; jacksonville FL 32218
• Manufacturer (Section G): BIOMET MICROFIXATION; 1520 tradeport drive; jacksonville FL 32218
• Manufacturer Contact: jennifer delaney ; 1520 tradeport drive; jacksonville, FL 32218 ; 9047414400
• MDR Report Key: 9578140
• MDR Text Key: 191983891
• Report Number: 0001032347-2020-00043
• Device Sequence Number: 1
• Product Code: JEY
• UDI-Device Identifier: 00841036123130
• UDI-Public: 00841036123130
• Combination Product (y/n): N
• Reporter Country Code: SZ
• PMA/PMN Number: K121589
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: foreign,health professional,u
• Reporter Occupation: Physician
• Type of Report: Initial
• Report Date: 01/10/2020

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 01/10/2020
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: N/A
• Device Catalogue Number: 24-1189
• Device Lot Number: 449720
• Was Device Available for Evaluation?: Yes
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Date Manufacturer Received: 12/13/2019
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 01/29/2019
• Is the Device Single Use?: No
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Reuse
• Removal/Correction Number: N/A
• Patient Sequence Number: 1