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SMITH & NEPHEW, INC. EVOS SMALL 2.0MM DRILL W/AO QC SHORT; INSTRUMENT, SURGICAL, ORTHOPEDIC, AC-POWERED MOTOR AND ACCESSORY/ATTACHMENT
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| Catalog Number |
71175021 |
| Medical Device Problem Code |
Fracture (1260)
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| Health Effect - Clinical Code |
No Clinical Signs, Symptoms or Conditions (4582)
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| Date of Event |
09/29/2023
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Type of Reportable Event
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Malfunction
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Event or Problem Description
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It was reported that, during an internal fixation, one evos small 2.0mm drill w/ao qc short broke off and snapped inside of one (1) 2.0/2.7mm double-ended drill guide.Nothing was left inside of patient anatomy.The procedure was resumed, without any delay, using a s+n back-up device.Patient was not injured as consequence of this problem.
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Additional Manufacturer Narrative
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H10: internal complaint reference: case-(b)(4).
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Additional Manufacturer Narrative
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The associated devices were returned and evaluated.A visual inspection of the returned device reveals multiple scratches, burrs and gouges in the device.There are no visual signs of breakage.The device shows signs of extensive wear and use.A functional evaluation reveals the evos small 2.0mm drill w/ao qc short is stuck inside the 2.0/2.7mm double-ended drill guide and cannot be removed which may be related to the alleged failure.A review of complaint history revealed similar events for the listed device over the previous 12 months, but no similar events for the batch based on the historical data, this failure mode will be monitored for future complaints for any necessary corrective actions.A review of the manufacturing records did not reveal a manufacturing abnormality that could have caused or contributed to the reported incident.At this time, we do not have reason to suspect that the product failed to meet any product specifications at the time of manufacture.A review of the risk management file revealed this failure mode was previously identified.The anticipated risk level is still adequate.Assessment of historical escalated cases concluded that there are no prior actions related to this device and failure mode.This device is a reusable instrument that can be exposed to numerous surgeries.Damage from prolonged use, misuse or rough handling are likely potential factors that could contribute to the reported event.We recommend that all reusable instruments be routinely inspected for wear and damage and replaced as necessary.Based on this investigation, the need for corrective action is not indicated.Should additional information be received, the complaint will be reopened.No further investigation is warranted for this complaint; however, we will continue to monitor future complaints and investigate as necessary.We consider this investigation closed.
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