MAUDE Adverse Event Report: STRYKER GMBH T2 FE RETRO NAIL LNG D9XL340; ROD, FIXATION, INTRAMEDULLARY AND ACCESSORIES

Model Number	2339-0934S
Medical Device Problem Codes	Break (1069); Fracture (1260); Material Deformation (2976); Material Twisted/Bent (2981)
Health Effect - Clinical Codes	Failure of Implant (1924); Nonunion/Delayed-union Bone Fracture (2369)
Date of Event	03/11/2023
Type of Reportable Event	Serious Injury
Event or Problem Description
As reported: "a voicemail came in today from a t&e sales rep from san antonio, tx regarding the breakage of 3 retrograde femur nails within a 9-day span.The nail bent at a 50 degree angle while the patient was doing rehab.This patient was revised with synthese nails.Patient had good bone quality.There was non-union.The patient adhered to all mobility instructions provided by the surgeon.
Additional Manufacturer Narrative
Upon completion of the investigation, additional information will be provided in a supplemental report.
Event or Problem Description
As reported: "a voicemail came in today from a t&e sales rep from san antonio, tx regarding the breakage of 3 retrograde femur nails within a 9-day span.The nail bent at a 50 degree angle while the patient was doing rehab.This patient was revised with synthese nails.Patient had good bone quality.There was non-union.The patient adhered to all mobility instructions provided by the surgeon.
Additional Manufacturer Narrative
The reported event could be confirmed, since the device was returned for evaluation and matches the alleged failure mode.The device inspection revealed the following: no major marks or signs were observed around the bend region indicating that no external force was applied to bend it.The bend in the plane is not supposed to be there as found upon comparison with the drawing.A dimensional inspection was conducted which revealed all the parameters to be within specification except for the bent region.A review of the manufacturing document revealed all the dimensions to be in specification and 100% of the lot was inspected.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.The above investigation reveals two aspects of this case.There was no anomaly found for manufacturing & design aspects.As per the manufacturing documents, all of the devices from the lot was inspected for all the critical dimensions.No deviation from the specifications was noticed.From the use aspect, a bend in the nail as significant as in this case, can be easily identified during insertion.Also, bending initially can be observed through follow-up x-rays.With such a bend, insertion of the nail won¿t be possible.Due to some remarkable circumstances the nail must bent post-operatively, the exact reason of which cannot be determined as more details like patient details, x-rays etc., are not available and are needed for a proper evaluation and finding the root cause.The instruction for use clearly advises the user about adverse effects like: "conditions attributable to non-union, osteoporosis, osteomalicia, diabetes, inhibited revascularization and poor bone formation can cause loosening, bending, cracking, fracture of the device or premature loss of rigid fixation with the bone." a deficiency of the nail was not verified.If any additional information is provided, the investigation will be reassessed.

• Brand Name: T2 FE RETRO NAIL LNG D9XL340
• Common Device Name: ROD, FIXATION, INTRAMEDULLARY AND ACCESSORIES
• Manufacturer (Section D): STRYKER GMBH; bohnackerweg 1; postfach; selzach 2545 ; SZ 2545
• 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: 16765823
• Report Number: 0009610622-2023-00125
• Device Sequence Number: 6034456
• Product Code: HSB
• UDI-Device Identifier: 07613327292459
• UDI-Public: 07613327292459
• Combination Product (Y/N): N
• Initial Reporter State: TX
• Initial Reporter Country: US
• PMA/510(K) Number: K203819
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2023
• Device Explanted Year: 2023
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 07/17/2023

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Operator of Device: Lay User/Patient
• Device Model Number: 2339-0934S
• Device Catalogue Number: 23390934S
• Device Lot Number: K0CD386
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 03/22/2023
• Supplement Date Received by Manufacturer: 06/21/2023
• Initial Report FDA Received Date: 04/18/2023
• Supplement Report FDA Received Date: 07/17/2023
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 11/22/2022
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Sex: Female