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ASCENSION ORTHOPEDICS, INC. CADENCE TALAR IMPACTOR; ORTHOPEDIC MANUAL SURGICAL INSTRUMENT
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| Catalog Number |
10203098 |
| 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 |
04/25/2024
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Type of Reportable Event
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Malfunction
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Additional Manufacturer Narrative
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H10: internal complaint reference: (b)(4).
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Event or Problem Description
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It was reported that, during surgery, the protector of one (1) cadence talar impactor broke at junction where end piece threads onto handle.All pieces were accounted for.The procedure was resumed, without any delay, using the same device (as implant was in place).Patient was not injured as consequence of this problem.
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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.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 revealed a similar event 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 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 this product and event.At this time, we have no evidence to conclude that the product failed to meet any specifications at the time of manufacture.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 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.Corrected data: g2.
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Additional Manufacturer Narrative
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Additional information: h6 (component code, type of investigation, investigation findings and investigation conclusions), h10 (roi).H6: the associated device was returned and evaluated.The threaded portion of the handle where it connects to the base was fractured.The fractured piece of the external thread was stuck in the internal threads of the base component.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 revealed a similar event 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 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 this product and event.At this time, we have no evidence to conclude that the product failed to meet any specifications at the time of manufacture.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 for future complaints and investigate as necessary.We consider this investigation closed.
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