MAUDE Adverse Event Report: STRYKER TRAUMA KIEL TARGET DEVICE GAMMA3®; ROD, FIXATION, INTRAMEDULLARY AND ACCESSORIES

Model Number 1320-0111

Device Problem Mechanical Jam (2983)

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

Event Date 04/21/2022

Event Type  malfunction  

Manufacturer Narrative

Based on the available information the device will not be returned therefore an evaluation of the device cannot be performed.Should additional information become available, it will be provided in a supplemental report.Device disposition unknown.

Event Description

It was reported: "the surgery was almost complete when the aiming device was to be removed, it was not detachable.The aiming device cannot be removed from the long gamma nail.There was a quasi cold connection between the implant and the insertion aid.Consequence: removal of the already fully implanted nail incl.Femoral neck screw and distal locking and re-implantation of a new nail.The procedure was delayed by 1h which lead to higher blood loss.".

Event Description

It was reported: "the surgery was almost complete when the aiming device was to be removed, it was not detachable.The aiming device cannot be removed from the long gamma nail.There was a quasi cold connection between the implant and the insertion aid.Consequence: removal of the already fully implanted nail incl.Femoral neck screw and distal locking and re-implantation of a new nail.The procedure was delayed by 1h which lead to higher blood loss.".

Manufacturer Narrative

Please note the correction to d9/h3 as the device was returned for evaluation.The reported event could be confirmed, since the device was returned for evaluation and matches the alleged failure mode.Device inspection revealed the following: the returned devices were received in a disassembled state.Proximal hole of targeting shows signs of damage along with damaged body indicating extensive usage.Upon closed look remnants/stains of dried blood were found in the screw insertion hole of targeting arm suggesting that blood percolated in assembly.The percolated blood in targeting arm most likely caused cold welding resulting in jamming of the devices making it difficult to disassemble post decontamination, pre-surgical test was conducted for the returned devices.Upon inspection, the devices were functionally ok.While inserting the nail holding screw in the target device slight resistance could be felt but parts could be assembled a review of the device history for the reported lot did not indicate any abnormalities.No corrective actions are required at this time.No indications of material, manufacturing or design related problems were found during the investigation.A review of the labeling did not indicate any abnormalities.Based on the above investigation, the root cause of the issue is most likely user related.The percolated blood in targeting arm most likely caused cold welding resulting in jamming of the devices making it difficult to disassemble if the device is returned or if any additional information is provided, the investigation will be reassessed.

• Brand Name: TARGET DEVICE GAMMA3®
• Type of Device: ROD, FIXATION, INTRAMEDULLARY AND ACCESSORIES
• Manufacturer (Section D): STRYKER TRAUMA KIEL; prof. kuentscher-strasse 1-5; schoenkirchen/kiel D-242 32; GM D-24232
• Manufacturer (Section G): STRYKER TRAUMA KIEL; prof. kuentscher-strasse 1-5; schoenkirchen/kiel D-242 32; GM D-24232
• Manufacturer Contact: anna jusinski ; 325 corporate drive; mahwah, NJ 07430 ; 2018315000
• MDR Report Key: 14487159
• MDR Text Key: 292481861
• Report Number: 0009610622-2022-00206
• Device Sequence Number: 1
• Product Code: HSB
• Combination Product (y/n): N
• Reporter Country Code: GM
• PMA/PMN Number: K123401
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Other
• Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date: 12/27/2022

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
• Device Operator: Health Professional
• Device Model Number: 1320-0111
• Device Catalogue Number: 13200111
• Device Lot Number: KME914953
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: No
• Initial Date Manufacturer Received: 04/28/2022
• Initial Date FDA Received: 05/24/2022
• Supplement Dates Manufacturer Received: 12/01/2022
• Supplement Dates FDA Received: 12/27/2022
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 04/27/2020
• 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 Sex: Male