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SMITH & NEPHEW, INC. FLEXIBLE DRILL 25MM; PROSTHESIS, HIP, FEMORAL COMPONENT, CEMENTED, METAL
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| Catalog Number |
71362925 |
| Medical Device Problem Codes |
Fracture (1260); Material Twisted/Bent (2981)
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| Health Effect - Clinical Code |
No Clinical Signs, Symptoms or Conditions (4582)
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| Date of Event |
03/12/2024
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Type of Reportable Event
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Malfunction
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Additional Manufacturer Narrative
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(b)(4).
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Event or Problem Description
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It was reported that, during a thr surgery, the flexible drill 25mm was coiled or "pig tailed", provided pictures show that the flexible drill 25mm fractured.The procedure was resumed, after a non-significant delay, with a s+n back-up device.No injury was reported as a consequence of this issue.
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Additional Manufacturer Narrative
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H3, h6: the device was not returned for evaluation; therefore, a device analysis could not be performed.However, the photographs were reviewed and revealed that the flexible shaft of the device is bent.No signs of breakage were found through this inspection.A review concluded that the event reported under this complaint was previously identified.It was concluded that the root cause of this issue was the shaft was not strong enough to resist high torques before failure of the shaft.The action taken was to add additional wires to the flexible shaft to make it stronger to resist higher torques.A review of complaint history of the previous 12 months revealed similar events for the part number with batches that were manufactured before and after the change of the device design.Therefore, an additional action, that is still in progress, was indicated to address the flexible shaft breakages/bending/pig-tailing, drill tip breakages/bending and drill tip not advancing properly into the bone.Device batch number was not provided, thus, an evaluation of the manufacturing records could not be performed.A review of the risk management file revealed this failure mode was previously identified.The anticipated risk level is still adequate.At this time, we have no evidence to suspect that the product failed to meet any specifications at the time of manufacture.Instrument design is the most probable root cause that could contribute to the reported event.Should the device or 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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