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SMITH & NEPHEW, INC. JOURNEY DCF AP FEM CUT BLK 9; PROSTHESIS, KNEE, FEMOROTIBIAL, SEMI-CONSTRAINED, CEMENTED, METAL/POLYMER
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| Catalog Number |
74012419 |
| 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 |
08/13/2024
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Type of Reportable Event
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Malfunction
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Event or Problem Description
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It was reported that during a tka, the journey dcf ap fem cut blk 9 broke straight through the number 2 slot when impacting.It is unknown at this time if pieces fell into patient.There was no delay and the procedure was finished using a smith & nephew back up.Patient was not harmed.
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Additional Manufacturer Narrative
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H10: internal complaint reference: (b)(4).H3, h6: this complaint was opened by smith+nephew to document a product problem associated with a smith+nephew device.The reported problem relates to known inherent device and/or procedural risks that are appropriately documented in our risk files.Smith+nephew will continue to monitor trends in accordance with our post-market surveillance process and take necessary action as required if anticipated severity and/or occurrence rates are exceeded.Smith+nephew has no reason to suspect that the product failed to meet any specifications at the time of manufacture.Based on our review of all currently available information, we are unable to identify a definitive root cause.However, as the use of our product cannot be excluded as a potential cause or contributory factor to the reported issue, we are conservatively submitting this report in accordance with applicable regulations.If additional information becomes available that alters the conclusions of this report, a follow-up report will be submitted as required.
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Additional Manufacturer Narrative
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H3, h6: the device was not returned for evaluation.However, the photographs was reviewed, and revealed that the second slot of the cutting block broke off from the device.A review concluded that a similar event was previously identified.There was a rework modification to include two 17-4 ph stainless steel pins press-fit perpendicular to the anterior face.This modification was made to improve the impact resistance of the cutting slots in the region.A review made by the quality engineering team revealed that per investigation and based on the photo received, this has been determined to be an isolated incident.The part in question was manufactured in 2013, making the part 11 years old.From the photo, it appears that the slot that was utilized the most after several uses had a significant amount of wear/usage to the edges where the saw blade often strikes while inside the slot.The part became too weak in these areas from the wear/usage over 11 years and ultimately broke/gave way once enough material had been removed.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 a similar event 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.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.
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