SMITH & NEPHEW, INC. JRNY II UNI RESECT AP BLOCK RM/LL SZ 7; PROSTHESIS, KNEE, FEMOROTIBIAL, NON-CONSTRAINED, CEMENTED, METAL/POLYMER
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Model Number 74016416 |
Device Problem
Flaked (1246)
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Patient Problem
Device Embedded In Tissue or Plaque (3165)
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Event Date 02/04/2020 |
Event Type
Injury
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Event Description
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It was reported that during use when the instrument was inside the patient, produced metal shaving when contacted by the drill in the femur prep process.There was a delay between 0-30 min.The surgery was finished with the same device.
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Manufacturer Narrative
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The affected complaint device, used in treatment, was not returned for evaluation.Therefore, a product analysis could not be performed and complaint could not be confirmed.The clinical/medical evaluation concluded that per the complaint details, the cut blocks produced metal shavings when contacted by the drill during the femur prep.S+n has not received the device and/or adequate documentation to fully evaluate the root cause of the reported event.Reportedly the procedure was completed with the same device within a 0-30 minute surgical extension.The patient impact beyond the reported minor surgical delay and the potential for retained metal shavings could not be determined.Should additional information/documentation become available, the clinical/medical task may be re-opened for further evaluation.No further medical assessment is warranted at this time.A complaint history review found related failures; this failure mode will be monitored for future complaints and assessed for any necessary corrective actions.At this time, we have no reason to suspect that the product failed to meet any product specifications at the time of manufacture.A review of the risk management file revealed this failure mode was previously identified.This device is a reusable instrument that can be exposed to numerous surgeries; damage from repeated use can occur.Damage from prolonged use, misuse or rough handling are likely probable causes of 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.Without the return of the actual product involved or product information, our investigation could not proceed.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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Manufacturer Narrative
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The associated device was returned and evaluated.A visual inspection of the returned device did not confirm the stated failure mode.The device did not show any signs of flaking or damage.A dimensional evaluation of the returned device did not confirm the stated failure mode.The device was found to be within specification.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.The clinical/medical evaluation concluded that this case reports that while using the journey ii cutting blocks metal shavings were produced when drilling.It is unknown if the metal shavings were removed from the patient.Without the requested clinical information, the reported issue could not be further assessed.The material for the device is 17-4 ph stainless steel and is manufactured and intended as an externally communicating device, not approved for implantation; therefore, long-term implantation data is not available.The patient impact beyond possible micro-motion and/or migration, and local irritation/discomfort cannot be determined.No further medical assessment can be rendered at this time.Should additional clinical documentation become available in the future, the clinical/medical task may be re-evaluated.A review of the manufacturing records did not reveal a manufacturing abnormality that could have caused or contributed to the reported incident.At this time, we do not have reason to suspect that the product failed to meet any product specifications at the time of manufacture.A review of the risk management file revealed this failure mode was previously identified.The anticipated risk level is still adequate.Assessment of historical escalated cases concluded that there are no prior actions related to this device and failure mode.A contribution of the device to the reported event could not be corroborated.Possible causes could include but not limited to surgical technique used or user/procedural variance.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 future complaints and investigate as necessary.We consider this investigation closed.
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