MAUDE Adverse Event Report: MEDTRONIC NAVIGATION, INC NAVLOCK 9736061 BLUE; ORTHOPEDIC STEREOTAXIC INSTRUMENT

Model Number 9736061

Device Problems Imprecision (1307); Device Sensing Problem (2917)

Patient Problem No Clinical Signs, Symptoms or Conditions (4582)

Event Date 03/24/2022

Event Type  malfunction  

Manufacturer Narrative

If information is provided in the future, a supplemental report will be issued.

Event Description

Medtronic received information regarding a guidance system being used during a spinal procedure.It was reported that navigation was inaccurate during a l4-s1 tlif procedure.The surgeon used an open, midline approach and a unilateral workflow starting on the left side and then moving to the right side.Navigation tools were placed down the arm guide and they were off trajectory.The drill, tap and screws were off.Navigation was off by 3-3.5 mm in the axial and lateral views.The accuracy of the surgical arm was checked with the passive planar probe being placed on the divot, and the arm was accurate.Anatomical checks were also accurate.The surgeon continued to use the guidance system to place screws.C-arm images were taken before and after placement and the screws were placed accurately.A new snapshot was not taken until the reference frames were switched from the robotic reference frame to the stealth air frame for the tlif portion due to the passive planar looking accurate when testing the divot on the arm guide as well as when navigating to known anatomical landmarks.There was no patient harm and the procedure was delayed less than an hour.Additional information received from a manufacturer representative reported that they suspected the inaccuracy was due to the instruments as several o ther cases were completed successfully with a different instrument tray.

Manufacturer Narrative

H3: analysis of the tracker found the complaint was not confirmed.The returned tracker has no physical damage.With markers attached and fully seated, the frame displays good geometry and divot error readings with normal tracking and verification.No problem found.Medtronic is submitting this report to comply with fda reporting regulations under 21 cfr parts 4 and 803.This report is based upon information obtained by medtronic, which the company may not have been able to fully investigate or verify prior to the date the report was required by the fda.Medtronic has made reasonable efforts to obtain more complete information and has provided as much relevant information as is available to the company as of the submission date of this report.This report does not constitute an admission or a conclusion by fda, medtronic, or its employees that the device, medtronic, or its employee caused or contributed to the event described in the report.In particular, this report does not constitute an admission by anyone that the product described in this report has any ¿defects¿ or has ¿malfunctioned¿.These words are included in the fda 3500a form and are fixed items for selection created by the fda to categorize the type of event solely for the purpose of regulatory reporting.Medtronic objects to the use of these words and others like them because of the lack of definition and the connotations implied by these terms.This statement should be included with any information or report disclosed to the public under the freedom of information act.Any required fields that are unpopulated are blank because the information is currently unknown or unavailable.A good faith effort will be made to obtain the applicable information relevant to the report.If information is provided in the future, a supplemental report will be issued.

• Brand Name: NAVLOCK 9736061 BLUE
• Type of Device: ORTHOPEDIC STEREOTAXIC INSTRUMENT
• Manufacturer (Section D): MEDTRONIC NAVIGATION, INC; 826 coal creek circle; louisville CO 80027
• Manufacturer (Section G): MEDTRONIC NAVIGATION, INC; 826 coal creek circle; louisville CO 80027
• Manufacturer Contact: glen belmer ; 7000 central avenue ne rcw215; minneapolis, MN 55432 ; 6122713209
• MDR Report Key: 14135730
• MDR Text Key: 289461211
• Report Number: 1723170-2022-00584
• Device Sequence Number: 1
• Product Code: OLO
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K124004
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Health Professional,Company Representative
• Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date: 04/25/2022

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 04/18/2022
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: 9736061
• Device Catalogue Number: 9736061
• Device Lot Number: 211115
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: Yes
• Date Manufacturer Received: 04/22/2022
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 10/31/2019
• Is the Device Single Use?: No
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Reuse
• Patient Sequence Number: 1
• Patient Age: 55 YR
• Patient Sex: Male
• Patient Weight: 77 KG