| Catalog Number |
209-30-00 |
| Medical Device Problem Code |
Break (1069)
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| Health Effect - Clinical Code |
Insufficient Information (4580)
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| Date of Event |
05/01/2020
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Type of Reportable Event
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Malfunction
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Additional Manufacturer Narrative
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Pending evaluation.
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Event or Problem Description
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During a revision from a primary to a cc, while locking the insert to the base plate, the ball tip driver broke, resulting in major difficulties to retrieve the broken tip left in the screw head.All pieces were retrieved, with less than 5 min delay to surgery.The tip was discarded and will not return, the driver will be returning.No patient info provided.
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Additional Manufacturer Narrative
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(h3) the fractured ball tip drivers reported may have been the result of using one of the torque limiting drivers that clicked over at a torque greater than 64 in-lbs., possibly due to corroded internal mechanisms.However, this cannot be confirmed as it is unclear which of the four torque limiting drivers from arago were used with the ball tip drivers when the fractures occurred.The higher torque values and/or reported ball tip driver breakages may also have been the result of a process failure as the torque testing process implemented in usa for instruments being serviced after return from the field prior to re-stocking was not implemented at all global offices.The most probable root cause associated with the reported event of "broken - minor surgical delay¿ is associated with a partial or full-thickness crack in the device materials.This is one of three products involved with the reported event and the associated manufacturer report numbers are 1038671-2020-00346, 1038671-2020-00347 and 1038671-2021-00167.
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Search Alerts/Recalls
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