Catalog Number 64-MT-0403 |
Device Problem
Device Dislodged or Dislocated (2923)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 07/31/2023 |
Event Type
Injury
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Event Description
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It was reported that an l5-s1 ct mis procedure was performed on (b)(6) 2023, utilizing the reform ct mis pedicle screw system.During the procedure four (4) ø6.5mm x 40mm reform ti modular cannulated screws (39-sk-6540) were removed from the caddy and the modular polyaxial tulip assembly reform mis pedicle screw system (64-mt-0403) was snapped on by hand.They were then given the slightest tug.The surgeon placed the screws on the left side, allowing the pa to place the right side screws.On the first screw at l5 on the left side the tulip disassembled.The screw was removed with the height adjuster and new screw and tulip readily available in the set were placed with no further issue.There was no patient injury with a slight delay of 3-5 minutes.
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Manufacturer Narrative
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H3 device evaluation - the parts were reviewed under magnification and the only damage noted was some deformation to the hexalobe, which is assumed to have occurred during extraction of the screw.The tulip and screw easily and audibly clicked together without issue.The assembly was then torqued down with a rod and cap-screw - once again without any observed issues.It is unclear as to why the disassembly occurred.Mechanical testing of properly assembled reform ti modular screws upon which this design is based demonstrates that reform ti modular assemblies are as strong as preassembled reform ti and slok polyaxial screws.Review of device history records found (b)(4) of lot 44286ps released for distribution on 6/2/2023 with no deviation or anomalies.Two-year complaint history review (7.31.2021-7.1.2023) found this to be the only report of this nature for this lot.Further review for all lots did not reveal a trend for reports of this nature.Although there was no product non-conformance identified, corrective actions were implemented by marketing to update the surgical technique guide to add additional instruction for tulip assembly.
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Search Alerts/Recalls
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