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It was reported that, when the surgeon was reaming during a total shoulder surgery, two (2) glenoid reamer driver snapped.Doctor completed with reaming as the second was deficient.The procedure was resumed, after a non-significant delay, with the same device.Patient was not harmed as consequence of this problem.
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H3, h6: the associated devices were returned and evaluated.The visual inspection revealed the prongs on the reusable instruments were bent/damaged.Additionally, part of the glenoid reamer driver tips were sheared off.Visual evaluation did note some signs of wear, including some striations on the driver near the mating end.Additionally, some nicks and scratches were noted on the mating end of the drivers.A review of the production order did not reveal a manufacturing abnormality that could have caused or contributed to the reported incident.A review of complaint history based on the historical data revealed similar events for the listed batch, this failure mode will be monitored for future complaints for any necessary corrective actions.A review of the risk management file revealed this failure mode was previously identified.The anticipated risk level is still adequate.A historical review concluded that there are no prior actions related to these products and event.At this time, we have no evidence to conclude that the products failed to meet any specifications at the time of manufacture.These devices are reusable instruments 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 for future complaints and investigate as necessary.We consider this investigation closed.
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