Model Number ROB10016 |
Device Problem
Break (1069)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 12/13/2021 |
Event Type
Injury
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Manufacturer Narrative
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Internal reference number: (b)(4).
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Event Description
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It was reported that while the surgeon was burring the tibia during a cori assisted tka surgery, the real intelligence robotic drill guard was spinning around the robotic drill attachment and suddenly was broken.The surgeon immediately stopped, removed the broken drill guard, disconnected broken piece from suction tubing, and inspected the patient for any pieces left behind.The surgeon confirmed all pieces were removed.The procedure was completed, with a one minute delay, using a second real intelligence robotic drill guard that was taken from the tray.Patient was not harmed beyond the problem reported.
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Manufacturer Narrative
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Internal reference number: (b)(4).
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Event Description
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It was reported that while the surgeon was burring the tibia during a cori assisted tka surgery, the real intelligence robotic drill guard was spinning around the robotic drill attachment and suddenly was broken.The surgeon immediately stopped, removed the broken drill guard, disconnected broken piece from suction tubing, and inspected the patient for any pieces left behind.The surgeon confirmed all pieces were removed.The procedure was completed, with a one minute delay, using a second real intelligence robotic drill guard that was taken from the tray.Patient was not harmed beyond the problem reported.
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Manufacturer Narrative
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The real intelligence robotic drill guard, (us) part number rob10016, lot1345066 used for treatment, was not returned for evaluation; thus, a visual and functional evaluation could not be performed, and a relationship between the reported event and the device could not be established.A review of manufacturing records indicate the device met all specifications upon release into distribution.A complaint history review for similar reported/confirmed complaints found similar events.Although the reported problem was not confirmed a factor that may have contributed to the reported symptom may have been associated with an incomplete weld around the perimeter of the irrigation tube.A historical escalation event review was not completed.The product was not returned and no evidence was made available to link the complaint to an escalation event.The real intelligence cori for knee arthroplasty user manual provides guidelines for recovering to a fully manual procedure in the "recovery procedure guidelines, appendix d".Per our risk assessment the failure mode and associated risk have been anticipated within the risk file and the documented risk level is still adequate.Per complaint details from us, it was reported that while the surgeon was burring the tibia during a cori assisted tka surgery, the real intelligence robotic drill guard was spinning around the robotic drill attachment and suddenly was broken.The surgeon immediately stopped, removed the broken drill guard, disconnected broken piece from suction tubing, and inspected the patient for any pieces left behind.The surgeon confirmed all pieces were removed.The procedure was completed, with a one minute delay, using a second real intelligence robotic drill guard that was taken from the tray.Patient was not harmed beyond the problem reported.Although no further containment or corrective action is recommended or required at this time, all complaints are monitored and trended through post market surveillance activities.If the product associated with this event is returned or provided at a future date, this evaluation will be reopened for investigation.
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Manufacturer Narrative
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The manufacturer has identified that this event should be re-evaluated for mdr reporting.The detached component is of a size/shape that can be easily retrieved in its entirety and this malfunction has been resolved by using an available back-up device.Although this event may result in a short delay while the procedure is resumed and completed as intended, this malfunction has not caused or contributed, in the past, to a death or serious injury, nor has it been required a medical intervention to preclude permanent impairment of a body function or permanent damage to a body structure.This malfunction is unlikely to cause any death or serious injury if it were to recur, either.Therefore, this event is considered non-reportable pursuant to 21 c.F.R.803.If further details are provided confirming the occurrence of a reportable event, our files will be updated accordingly, and a further report submitted outlining both the event details and our investigations performed.
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Search Alerts/Recalls
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