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It was reported that during a trigen retrograde nailing, the capture mechanism tip of a medium hexdriver snapped and was retrieved using tweezers.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 information: h6 (component code, type of investigation, investigation findings, investigation conclusions), h8 (use of the device).Results of investigation: the associated device was returned and evaluated.The visual inspection revealed that a piece of the threaded tip of the hexdriver shaft broke off.This piece was not returned.The hexdriver shaft and hex driver were both returned.The device shows signs of extensive wear and use.This inspection was conducted by naked eye.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 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 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.Corrected data: d9&h3 (sample returned for analysis).
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