This follow-up report is being submitted to relay additional information.The following sections were updated/corrected.The subject device was evaluated onsite several times by a field service engineer and an engineer approximately a month after this complaint.Additionally, an analysis was also performed by a subject matter expert.It was concluded the device was performing as intended.There were no software or hardware anomalies identified while evaluating the device.Vibrations of the arm were only reproducible when positioning the pointer with strong pressure, which is not recommended.Observations in the video provided also confirm rapid actuations of the vigilance device, which is also not recommended.Regarding claims of inaccuracy, it was noted that 3 bone fiducial were mounted on the screw of the stereotactic frame, where 5 are recommended.Additionally, the method used by the surgeon to measure the entry point (robot and pointer tool) with the medial point on the patients head was also challenged as potentially inaccurate and not in line with the verification process in the rosa brain application user manual.A subject matter expert preformed an evaluation of the available information.A clinical manager was onsite to assist the surgeon during a subsequent procedure and confirmed the surgeon was not following the recommended protocol, resulting in perceived inaccuracy of the system.The protocol for verification was reviewed and reinforced with the surgeon, resulting in no issues and good accuracy in the subsequent procedure.A review of the device history record has been completed.This review did not identify any contributory factors to the event.Based on the investigation performed, the technical root cause of the event was determined to be user error in not following the recommended protocol for fiducial registration or verification.Clinical manager provided the surgeon the proper surgical technique and use of the device.If any further information is found which would change or alter any conclusions or information, a supplemental will be filed accordingly.Zimmer biomet will continue to monitor for trends.
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