MAUDE Adverse Event Report: SMITH & NEPHEW ORTHOPAEDICS AG POLARSTEM COLLAR REAMER GUIDE; PROSTHESIS,HIP,SEMICNSTRIED,METAL/CERAMIC/POLYMER,CEMENTED,UNCMNTD

Model Number	75102205
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	02/10/2020
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that the device failed during procedure.It was confirmed, in an additional information, that the device broke, however no pieces fell inside the wound.All fragments were disposed.
Additional Manufacturer Narrative
A polarstem collar reamer guide (75102205), used in treatment, was not received for evaluation.It was reported that the device failed during the procedure.It was confirmed, in an additional information request, that the device broke, however no pieces fell inside the wound.All fragments were disposed.A visual analysis could not be conducted, as the part was not returned.The production documentation was reviewed, however there were no deviations found.The review of the complaint database showed that similar cases were reported in the past, one of which led to a corrective and preventive action.A design review was performed which demonstrated that the hook may contact the reamer if it is not fully engaged in the rasp during reaming.This is likely to lead to a fracture of the hook and the spring might become loose as reported here.It is therefore assumed that foreign material prevented the hook from fully engaging with the rasp, which led the reamer to hit and fracture the hook intraoperatively.A new design of the device has been released in order to prevent the reoccurrence of this issue.The failure mode cannot be independently confirmed as the part was not returned.The root cause is attributed to insufficient design specifications.Further investigations have been initiated to review the performance of this device.This complaint has been reopened for reporting reasons, according to the current procedure.No additional information became available.Should the device be returned, this complaint will be reassessed.Smith and nephew will monitor this version of the device for further similar issues.

• Brand Name: POLARSTEM COLLAR REAMER GUIDE
• Common Device Name: PROSTHESIS,HIP,SEMICNSTRIED,METAL/CERAMIC/POLYMER,CEMENTED,UNCMNTD
• Manufacturer (Section D): SMITH & NEPHEW ORTHOPAEDICS AG; schachenallee 29; baar 06340 ; SZ 06340
• Manufacturer (Section G): SMITH & NEPHEW ORTHOPAEDICS AG; schachenallee 29; aarau CH500 0; SZ CH5000
• Manufacturer Contact: sarah freestone ; oberneuhofstrasse 10d; baar 06340 ; SZ 06340 ; 0447940038246
• MDR Report Key: 10200775
• Report Number: 9613369-2020-00132
• Device Sequence Number: 16412357
• Product Code: LZO
• UDI-Device Identifier: 00885556535493
• UDI-Public: 00885556535493
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K143739
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Health Professional,User Facility,Company Representative
• Initial Reporter Occupation: Other Health Care Professional
• Remedial Action: Recall
• Type of Report: Initial,Followup,Followup,Followup
• Report Date (Section B): 09/15/2022

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Model Number: 75102205
• Device Catalogue Number: 75102205
• Device Lot Number: A57539
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Initial Date Received by Manufacturer: 02/10/2020
• Supplement Date Received by Manufacturer: 07/13/2020; 09/01/2022; 09/01/2022
• Initial Report FDA Received Date: 06/26/2020
• Supplement Report FDA Received Date: 07/18/2020; 09/02/2022; 09/15/2022
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 07/02/2015
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Reuse
• If action reported to FDA under 21 USC 360i(g), list FDA-assigned Recall Number or include a statement: Z-2827-2020
• Patient Sequence Number: 1
• Patient Sex: Unknown