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The complaint device was evaluated and the reported event was confirmed.The evaluation identified the device exhibited a fractured off distal articulating jaw.A definitive cause of the pituitary rongeur jaw fracture cannot be determined; however, based on previous investigations for similar events, pituitary rongeur jaw fracture can occur when off-axis excessive force and/or excessive twisting motions are placed on the device during use.Labeling review: ".Instrument malfunctions which potentially result in surgical delays (thereby causing additional exposure to anesthesia, blood loss, and infection), a change in surgical plan, failure to achieve optimal clinical result and/or, infrequently, cancellation of a procedure.Such malfunctions include instrument fracture, which could make necessary removal difficult or sometimes impossible, with possible consequences of late infection and migration; instrument fracture may also result in injury to the patient." ".Pre-operative warnings: the method of use for the instruments are to be determined by the user¿s experience and training in surgical procedures.The instruments should be treated as any precision instrument and should be carefully placed on trays, cleaned after each use, and stored, according to generally accepted hospital methods and practices.The instruments should be carefully examined prior to use for functionality, excessive wear, or damage.A damaged instrument should not be used as this may increase the risk of malfunction and potential patient injury." ".Intra-operative warnings: the physical characteristics required for many instruments do not permit them to be manufactured from implantable materials.If any broken fragments of instruments remain in the body of a patient, they could cause allergic reactions or infections.If an instrument breaks in surgery and fragments go into the patient, these pieces should be removed prior to closure and should not be implanted." if any further information is obtained that would change or alter any information provided, a supplemental report will be filed accordingly.
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The pituitary rongeur was initially reported to have broken during use in a procedure with no additional details provided.However, during analysis of the device by the manufacturer, it was determined the device exhibited a fractured off distal tip.There was no reported adverse impact to the patient, user, or procedure in association with the fractured off tip.No additional information is available.
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